Medicine case discussion

 I’ve 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

K.shirisha

Rollno;68

30yr /F admitted in Superspeciality ward 

Chief complsints

C/o chest pain (substernal,dragging type) since 2years 

C/o Pain in Right Hypochondrium since 6months 

C/o itching sensation in right hypochondriac region since 6months 

Hopi:

Patient was apparently alright 2years ago then she started experiencing chest pain (substernal, dragging type), continuous type, Radiating to the back interscapular area , aggravated on movement, raising arms above the shoulder or bending forward and at night after lying down,slightly relieved in the morning 

Associated with nausea and headache 

Relieved on taking PPI and sucrafyl syrup 

No h/o shortness of breath, palpitations/excessive sweating, Orthopnea or pnd

She also started having dragging type pain in the right hypochondriac region, occasionally after having spicy food since 6months, after 30mins after eating, which lasts for 15mins and relieves spontaneously 

No radiation of pain

There is change in colour of stools- black colour occasionally in the last 6months 

No h/o loose stools , vomiting, burning micturation, fever 

Occasionally Itching sensation is present in the right hypochondriac region since 6months 

(Even if pain is not there) 

Past history:

Not a known case of hypertension, diabetes, thyroid disorder , CVA,CAD,TB, ashthma, epilepsy 

Family history: insignificant

Personal history:

Appetite: normal

Diet: mixed

Bowel and bladder : regular

Sleep: adequate

General examination:

Patient is conscious, coherent, cooperative

Temperature: Afebrile

Pulse- 92/min 

BP-120/70mmhg 

RR: 16cpm

Spo2: 98% on RA

pallor was present 

No icterus,cyanosis,clubbing, lymphadenopathy,edema

Systemic examination

Per abdomen

Inspection;

Shape; distended 

Umbilicus; central

Movements ; normal

No visible pulsations or engorged veins,no visible peristalsis

Skin over abdomen ;normal

✓Palpation;

Soft, tenderness present around the umbilicus

No organomegaly

✓Percussion ;

Liver; resonant note heared

shifting dullness- -

No fluid thrills,

✓Auscultation;

Bowel sounds are heared

CVS- s1s2 heard; no murmur

Respiratory- B/L air entry present ; no added sounds heard

CNS:

Higher mental functions intact

Reflexes- present

Power,muscle tone- normal

Gait- normal

No meningeal signs

Cranial nerves - intact

Diagnosis:. CHRONIC GASTRITIS

                    

SPODYLOARTHROPATHY ASYMMETRICAL SACROILEITIS COSTOCHONDRITIS

Investigations:

Hemogram:

HB: 9.8g/dl

TLC:7200

N: 52

E:02

L:38

B:00

M:08

PCV:32

MCV:83.3

MCH:25.5

MCHC:30.6

RDW CV:15.1

RDW SD:46

PC:1.52lakhs

RFT:

Blood urea: 32

Serum creatinine: 0.6

LFT:

TB: 1.02

DB:0.20

AST:26

ALT:34

ALP:100

Tp: 7.4

Alb: 4.2

A/G:1.35

X ray chest:

USG abdomen:

ECG:

Upper GI endoscopy:

https://youtu.be/gEDPJYK7vSo

Previous reports:

Upper GI endoscopy:

Impression:

Small superficial antral ulcer

Treatment:

1) Tab pan 40mg/po/od

2) Tab Brufen 400mg/po/BD

3) Avoid spicy foods