Skip to main content

70 YEAR OLD MALE WITH EPIGASTRIC PAIN SINCE 1 YEAR AND DYSNPNEA

 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 patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome." 

CHIEF COMPLAINTS 

1. Dyspnea at rest since 2 years 

2.epigastric pain since 1 year 

3.water brash since 1 year 

HISTORY OF PRESENTING ILLNESS 

Patient is a resident of Nalgonda , a unskilled labourer by occupation for the last 50 years 

he was apparently leading a normal life until 2 years back when he developed shortness of breath on doing more than ordinary physical activity , (grade -2) , which currently progressed to (grade -4)even at rest .

Dysnpnea was not associated with orthopnea, PND ,bendopnea, trepopnea .

one year later 

patient started with a feeling of water brash , sour taste in his mouth immediately after eating food , as days passed by he even developed epigastric burning pain, radiating into the chest , gradually he lost his appetite.

(currently eats in fairly smaller portions and less frequently than before )

This continued for a month 

Concerned about his condition  , he was taken to RVM hospital where he underwent investigations in view of his epigastric pain 

He underwent upper GI endoscopy,CT scan  ,ECG and USG and blood work 

He was diagnosed with GERD, with multiple gastric erosions and USG showed b/l renal calculi 

Patient was even medication was his dyspepsia 

Though he took medication  his symptoms last till date 

since last 2 months  patient has also developed giddiness on walking 

For which he visited local hospital was prescribed 

Mutli- vitamins 

at this point , he was frustrated with his condition , multiple visits at the hospital and still no cure to his state 

he was brought to us today (16-08-2023) at 2:00pm 

PAST HISTORY 

not a known case of HTN , DM, epilepsy ,asthma , copd ,thyroid disorders , any psychiatric conditions .

PERSONAL HISTORY 

Patient is married, with one son and two daughters 

he has worked as a unskilled labourer for the last 50 years 

Stopped working 2 months ago 

his daily routine 

8:00 am - wakes up 

9:30 am - showers and has breakfast and takes his lunch box and leaves for work 

1:00pm- takes a break from work and has his lunch 

5:00 pm - continues to work until then , takes his daily wage and comes home 

7:30 pm - showers and performs his namaz for the day 

9:00pm - dinner is done by this time and lays to sleep 

( symptoms of epigastric pain are not aggravated on laying down , nor do they have any diurnal variation ) 

His meal time are always scheduled on time .

FAMILY HISTORY 

No similar complaints in family .

GENERAL EXAMINATION 


Patient is moderately built and moderately nourished well oriented to time , place , person 



patient has hoarse voice , and is Dyspnic even at rest .

VITALS 

TEMP -afebrile on touch 

PULSE RATE -86bpm

PULSE PRESSURE -120/80mmHg

RESPIRATORY RATE -22cpm



SYSTEMIC EXAMINATION 

CVS

Elliptical & bilaterally symmetrical chest

-No visible pulsations/engorged veins on the chest

-Apex beat seen in 5th intercostal space medial to mid clavicular line

-S1 S2 heard

-No murmurs


RESPIRATORY SYSTEM


Upper respiratory tract normal

  Lower respiratory tract :

-Trachea is central

-Movements are equal on both sides

-On percussion resonant on all areas

-Bilateral air entry equal

-Normal vesicular breath sounds heard

-No added sounds

-Vocal resonance equal on both sides in all areas


CNS 


Higher mental functions

-Patient is conscious, coherent,co-operative.Oriented to time, place,person.

-Speech = Fluency,comprehension,repetition intact

-Memory =Recent,Remote,Immediate : Intact

Cranial nerve examination -

other cranial nerves are normal

Motor examination :

Bulk of muscle normal on both sides on inspection


Tone  

                          Right.             Left 

Upper limb.    Normal.           Normal


Lower limb.    Normal.           Normal


POWER


upper limbs and lower limbs  +5 in all proximal and distal muscles 


Investigations 






provisional diagnosis 

Disease involving the gastrointestinal system , GERD ?LPR?with hoarness of voice indicating vocal cord destruction due to chronic stomach acid exposure ?dysnpnea due to ?


Comments

Post a Comment

Popular posts from this blog

Image
  60 Year Old Female with CKD on Maintenance Haemodialysis...... December 05, 2023 This is an online E - log book to discuss our patients 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 patient’s clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online portfolio and your valuable inputs on the comment box. December 05,2023 I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings investigations and come up with diagnosis and treatment plan. A 60 year old female resident of suryapet farmer by occupation came to the OPD with CHIEF COMPLAINTS : Swelling of both le
Read more

OSCE and learning points

Image
Symptoms of  Right and Left heart failure:- Preload and Afterload: Preload : Preload is volume of blood received by the heart. Basically preload is stretch.It is the ventricular stretch at the end of diastole. Occurrence : during diastole Depends on : The amount of ventricular filling. Preload is a volume. Affecting factors : venous blood pressure and the rate of  venous return.  Afterload :  Afterload is the pressure that the Chambers of the heart must generate in order to eject blood out of heart. Occurrence : during systole Depends on : The arterial blood pressure and vascular tone. Afterload is a pressure. Affecting factors : systemic vascular resistance and pulmonary vascular resistance  Pathophysiology:- LEARNING POINTS:- :- I have learnt how important is to take delailed history  :- I have learnt how important is the daily routine and occupation of the patient :- How essential it is to build communication with the patient and patient attender to gain thei
Read more

45 years old female with shortness of breath

Chief complaints :  Fever since 10 days Giddiness since 3 days Dry cough since 3 days Loose stools since 1 day Vomiting since 1 day History of present illness : Patient was apparently asymptomatic since 10 days and then she developed fever which is associated with the chills and rigor and with diurnal variation increased during night and subsided by night and she had giddiness and shortness of breath since 3 days and then for which she went RMP doctor and he gave ORS and from then she had 1 episode of vomiting non projectile non bilious contains food particles and she had 1 episode of loose stools since 1 day and she has history of dry cough since 3 days . History of past illness :  She is not known case of diabetes, hypertension, epilepsy,CVA,CAD, thyroid disorders. PROVISONAL DIAGNOSIS :  Acute pulmonary Koch  S  Dry cough  Stool passed +  No Fever spikes  Decreased tingling sensation of wrists  O  Pt is conscious ,coherent , cooperative Temp:  BP: 100/70 mmHg  PR : 72 bpm  RR :  24c
Read more