A 60 year old male patient with indigestion
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Chief Complaints:
Patient complaints of indigestion since 4months
History of Present Illness:
Patient was apparently asymptomatic 4months ago he then noticed indigestion
H/o B/l knee joint pain since 1 year
H/o chest pain (on right and left side) non radiating, burning,spasmodic type of pain since 3 months
No h/o excessive sweating, palpitations,pedal edema, giddiness
H/o abdominal distension and bloated sensation after eating food
No h/o headache, vomitings, loose stools and pain abdomen
History of Past illness:
H/o Diabetes since 3 1/2 year
No h/o hypertension, TB,asthma,CAD
Personal History:
Married
Daily wage labour
Appetite-normal
Diet-Mixed
Bowel movement-Normal
Micturition-normal
Habits-smoking since 25years and now stopped
Family History:
No members of the family the similar condition
General Examination:
Vitals:
Temp:96.8
Respiratory rate:18cycles/min
Pulse: 90bpm
Blood pressure:130/80mmhg
Sp O2 -97%
GRBS-287mg/dl
Systemic Examination:
Cardiovascular Examination:
Thrills:no
Cardiac sounds:S1,S2 heard
Cardiac murmurs:no
Respiratory system:
Dyspnea: yes
Wheeze:no
Position of trachea: central
Breath sounds: vesicular
Adventitious sounds:no
Abdomen
Shape of abdomen: scaphoid
Tenderness:no
Palpable mass:no
Henias orifices: normal
Free fluid:no
Bruits:no
Liver: not palpable
Spleen:not palpable
Bowel sound:no
Central Nervous system:
Pt is conscious
Speech: normal
Signs of meningitis:
Neck stiffness:no
Kerning sign:no
Cranial nerves: normal
Motor and sensory system: normal
Provisional Diagnosis:
Peptic ulcer
Investigation:
HEMOGRAM:-
Hb-13.4 g/dl
TLC-
Lymphocytes-41%
MCV-74.3fl
MCH-24.5pg
Platelets-2.2lakhs/cumm
RBC-5.45 million/cumm
Albumin-Trace
Sugar-++++
Pus cells-2-3/HPF
Epithelial cells- 3-4/HPF
Blood urea-23mg/dl
Serum creatinine-1.0mg/dl
LFT:-
TB-1.05mg/dl
DB-0.25mg/dl
AST-14
ALT-15
Alkaline phosphatase-22l
Total protein-6.8g/dl
Albumin-3.89g/dl
A/G ratio-1.3
SEROLOGY:-
HbsAg-negative
HSV-negative
HIV-negative
Treatment:
Tab PAN 40mg PO/OD
Tab MVT PO/OD
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