PAIN IN EPIGASTRIC REGION

CBBLE UDHC SIMILAR CASES

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

60 year male,farmer by occupation came with chief complaints of epigastric pain since 2 yrs.

Patient was apparently asymptomatic 2yrs back,then developed epigastric pain,insidious in onset and radiating to back and neck area,dragging type of pain,relieved on taking medication. 

No intolerance to spicy food,no radiation to arms

C/o ulcer on ventral surface of right calf since 20 days initially,only itching was present.gradually tingling sensation started in that area.

No h/o discharge, trauma or insect bite.edema present around ulcer area.

C/o loss of appetite since 2 months,due to worsening of epigastric pain.

C/o bitter taste in mouth.

PAST HISTORY:

Not a K/C/O DM,HTN, EPILEPSY, TB.

PERSONAL HISTORY:

DIET - MIXED,

APPETITE -DECREASED

BOWEL MOVEMENT - REGULAR , 

BLADDER MOVEMENTS - REGULAR, ADDICTIONS(ALCOHOL AND SMOKING) - NO ADDICTIONS

TREATMENT HISTORY:

NON SIGNIFICANT 

O/E:

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

 NO ICTRUS 

 NO PALLOR 

No CLUBBING , CYANOSIS , LYMPHADENOPATHY, EDEMA

VITALS - 

TEMPERATURE - 97' F

PULSE RATE - 89BPM

BLOOD PRESSURE - 130/80 MM OF HG 

RESPIRATORY RATE - 17

SPO2 - 99 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

P/A - diffuse tenderness present, no organomegaly

INVESTIGATIONS:

HB-12

TLC-7900

N/L/M/E-70/20/6/4

PLT-2.25

PCV-35%

RBC-4.24

SERUM CREATININE-0.8

Na-143,k-3.9,Cl-99

LFT:TB-0.8,DB-0.2,AST-18,ALT-11,ALP-131,TOTAL PROTEIN-5.8,ALB-3.9A/G: 2.19

RBS-97

SEROLOGY-NEGATIVE.

ECG-

chest x ray:

X RAY OF C SPINE:

DIAGNOSIS:PAIN IN EPIGASTRIC REGION. 

TREATMENT:

1.INJ.PANSEC 40 MG IV 1-×-×(AFTER  TEST DOSE ONLY)

2.SYP.MUCAINE GEL 2TBP 1-1-1