Third BDS prefinal practical examination

Welcome and greetings to every one who are visiting my blog.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 patients 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 comment box is welcome.

Chief complaint :
A 55 year old male came to OPD complaints of left side chest pain since 15 days
Right chest pain which is radiating to back and also complaints of body pains, headache, sleeplessness.
 History of present illness:
Patient was apparently asymptomatic 15 days then he developed left chest pain which is radiating to back and also complaints of right side chest pain.
Dry eyes,dry mouth
No h/o fever, nausea, vomiting
Patient went to nalgonda govt hospital intially with same complaints and got basic investigations done he now came to casualty for further management

History of past Illness:
No h/o diabetes mellitus, asthma,hypertension, epilepsy, tuberculosis, hepatitis and cvs problems

Personal history:
Diet- mixed with normal appetite
Bowel and bladder movements - normal
Sleep- inadequate
Alocholic since 20 years
No known relevant drug history
Family history: no known relevant family history

General examination:
Patient is conscious, coherent, cooperative and we'll oriented to time,place and person
Moderately built and nourished
No features indicating the presence of:
Pallor, icterus, cyanosis, clubbing of fingers,edema, lymphadenopathy.

Vitals:
Temperature: afebrile
Pulse rate: 72 beats per min
Blood pressure: 130/80mmhg
Respiratory rate: 18 cycles per min

Systemic examination:
 CVS- s1and s2 heart sounds heard and no cardiac murmurs
No thrills
 Abdomen:
Inspection;
Shape of the abdomen: obese, with no distension.
Umbilicus: inverted
No scars are seen
No dilated veins
No visible pulsation
No localised swellings

Palpation: 
No local rise of temp
No tenderness
No splenomegaly
No hepatomegaly

Percussion: 
Liver span- 12cm
Fluid thrills- absent
Shifting dullness - absent
Puddle sign- absent

Auscultation:
Bowel sounds present
No bruits

Respiratory examination:
Normal vesicular breath sounds heard
 
Provisional diagnosis:
Alocholic gastritis 

Investigations:

Hemogram-
Hb-14.9gm/dl
Total leucocyte count- 8300 cells/cumm
Platelets - 4.4lakhs/cum

Treatment:
Tab: pan-40mg/po od
Tab: ecosprin 75mg po od
Tab: atrovas 10mg po od 






 

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