45 yr old male with Non ulcer Dyspepsia

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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 45 yr old male was farmer 10 yrs back , now working as business man. 

Came with complaints of burning sensation  since 3 days.

HOPI : pt was apparently asymptomatic  2 1/2 yrs back, then he complained of pain in lower abdomen ( right illiac fossa), associated with vomitings and fever.

It was diagnosed as appendicitis ,for which he was operated.( Appendicectomy) now, patient  complaints of  burning sensation in epigastric region, associated with nausea( with intake of food) ,and relieved on taking medication.

Past history : pts has similar complaints   of pain   since 2 yrs which was intermittent which increased on intake of meat( non vegetarian food), he also complaints of blood in stool

Not a k/C/O DM,HTN, Asthma,TB, Epilepsy

General examination :

Pt is C/C/C

Temp- afebrile

BP: 110/70 mmhg

PR: 76 BPM

RR :16 CPM

No pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema

SYSTEMIC EXAMINATION 

CARDIOVASCULAR SYSTEM:

Inspection:

Chest wall is bilaterally symmetrical.

No precordial bulge

No visible pulsations, engorged veins, scars, sinuses

Palpation:

JVP: normal

Apex beat: felt in the left 5th intercostal space in the mid clavicular line.

Auscutation:

S1, S2 heard , No murmurs

RESPIRATORY SYSTEM-

Position of trachea: central

Bilateral air entry +

Normal vesicular breath sounds - heard

No added sounds.

PER ABDOMEN:

Abdomen is soft and non tender

No organomegaly.

Bowel sounds heard.

No palpable mass or free fluid 

CENTRAL NERVOUS SYSTEM:

Patient is Conscious 

Speech: normal

No signs of Meningeal irritation

Motor & sensory system: normal

Reflexes: present

Cranial nerves: intact

Diagnosis : Acute gastritis

Treatment :

1. Tab PAN 40 MG PO OD

2. Tab . MCT PO OD

3. SYP. SUCRALFATE 10 ml PO TID

 

SOAP notes - Day 1

Ward Case 

45/M 

S : mild abdominal pain

O :

Pt c/c/c

Temperature : 98.6 F

BP : 110/70mm Hg

PR : 76bpm , regular

CVS : S1 S2 +, no murmur

RS : NVBS + , no crepts

P/A : soft, non tender

CNS : NFND 

A :

Acute Gastritis

P : 

1. Tab.PAN 40 MG PO OD

2. Tab.MVT PO/OD

3.SYP.SUCRALFATE 10ML PO TID

SOAP notes - Day 2

Ward Case 

45/M 

S :

4 episodes of soft stools since yesterday night 

O :

Pt c/c/c

Temperature : 98.4 F

BP : 100/70mm Hg

PR : 76bpm , regular

CVS : S1 S2 +, no murmur

RS : NVBS + , no crepts

P/A : soft, non tender

CNS : NFND 

A :

Acute Gastritis

P : 

1. Tab.PAN 40 MG PO OD

2. Tab.MVT PO/OD

3.SYP.SUCRALFATE 10ML PO TID

SOAP notes Day -3

Ward Case 

45/M 

S : mild abdominal pain

O :

Pt c/c/c

Temperature : 98.6 F

BP : 110/70mm Hg

PR : 80bpm , regular

CVS : S1 S2 +, no murmur

RS : NVBS + , no crepts

P/A : soft, non tender

CNS : NFND 

A :

Acute Gastritis

P : 

1. Tab.PAN 40 MG PO OD

2. Tab.MVT PO/OD

3.SYP.SUCRALFATE 10ML PO TID

Discharge

Date:02/10/2021

Ward:GM WARD

Unit:3

Name of Treating Faculty

DR.CRAZY(INTERN)

DR.VARUN(INTERN)

DR.PAVAN(INTERN)

DR.YASHWANTH(INTERN)

DR.BRIGISHA(INTERN)

DR.RAVEEN(PGY1)

DR.VAISHNAVI(PGY2)

DR.RAKESH BISWAS

Diagnosis

ACUTE GASTRITIS

Case History and Clinical Findings

A 45 YR OLD MALE PATIENT CAME WITH COMPLAINT OF CHRONIC ABDOMINAL PAIN SINCE

2 1/2 YRS .

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 1/2 YRS BACK AND THEN DEVELOPED PAIN

AT RT ILIAC FOSSA, FEVER, VOMITINGS, FOR WHICH APPENDICECTOMY WAS DONE

20 DAYS AFTER THE SURGERY PT JHAD C/O BURNING SENSATION IN EPIGASTRIAC

REGION, ASSOCIATED WITH NAUSEA, AFTER INTAKE OF FOOD, RELIEVED ON MEDICATION

SIMILAR COMPPLAINTS SINCE PAST 2 YEARS

INTERMITTENTLY AFTER INTAKE OF MEAT (NON VEG)

WHILE PASSING STOOLS PATIENT HAD C/O DROPS OF BLOOD IN STOOL

PAST H/O- NOT A K/C/O DM,HTN,TB,EPILEPSY

PAST SURGICAL H/O: APPENDICECTOMY DONE 2 1/2 YRS BACK

GENERAL PHYSICAL EXAMINATION

PT IS C/C/C

NO PALLOR, ICTERUS, CLUBBING, CYANOSIS, ODEMA OF FEET

TEMP- AFEBRILE

PR- 78 BPM

BP- 120/80 MM/ HG

RR- 16 CPM

SYSTEMIC EXAMINATION:

CVS- S1, S2 +

RS- BAE+

CNS- NAD

Investigations

HBsAg-RAPID 30-

09-2021 09:14:AM

Negative Kit Name:

Virucheck

Anti HCV Antibodies

- RAPID 30-09-2021

09:14:AM

Non Reactive Kit

Name:Life Band

BLOOD UREA 30-

09-2021 09:14:AM

19 mg/dl 42-12 mg/dl SERUM

CREATININE 30-09-

2021 09:14:AM

0.9 mg/dl 1.3-0.9 mg/dl

 SERUM ELECTROLYTES (Na, K, C l) 30-09-2021 09:14:AM

 SODIUM 143 mEq/L 145-136 mEq/L

 POTASSIUM 4.6 mEq/L 5.1-3.5 mEq/L

 CHLORIDE 100 mEq/L 98-107 mEq/L

 LIVER FUNCTION TEST (LFT) 30-09-2021 09:14:AM

 Total Bilurubin 0.67 mg/dl 1-0 mg/dl

 Direct Bilurubin 0.18 mg/dl 0.2-0.0 mg/dl

 SGOT(AST) 19 IU/L 35-0 IU/L

 SGPT(ALT) 16 IU/L 45-0 IU/L

 ALKALINE

PHOSPHATE

188 IU/L 128-53 IU/L

 TOTAL PROTEINS 6.6 gm/dl 8.3-6.4 gm/dl

 ALBUMIN 4.3 gm/dl 5.2-3.5 gm/dl

 A/G RATIO 1.88

 COMPLETE URINE EXAMINATION (CUE) 30-09-2021 09:14:AM

 COLOUR Pale yellow

 APPEARANCE Clear

 REACTION Acidic

 SP.GRAVITY 1.010

 ALBUMIN Nil

 SUGAR Nil

 BILE SALTS Nil

 BILE PIGMENTS Nil

 PUS CELLS 3-4

 EPITHELIAL CELLS 2-3

 RED BLOOD CELLS Nil

 CRYSTALS Nil

 CASTS Nil

 AMORPHOUS

DEPOSITS

Absent

 OTHERS Nil

Treatment Given(Enter only Generic Name)

1. SYP. SUCRALFATE 10 ML /PO/TID BEORE FOOD

2. TAB. PANTOP40 MG /PO/ OD BBF

3.TAB. MVT PO/OD

Advice at Discharge

1. SYP. SUCRALFATE 10 ML /PO/TID BEORE FOOD

2. TAB. PANTOP40 MG /PO/ OD BBF

3.TAB. MVT PO /OD

Follow Up

REVIEW AFTER ONE WEEK

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER

SIGNATURE OF PG/INTERNEE

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY