63yr/M Pain Abdomen

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

Dr. Lohith Varma 

PGY1 - GM 

Long distance patient- 63yr/M 

* Chief complaints-

   chest pain(burning sensation) 3months 

* Bloating sensation since 1yr 

* incomplete evacuation of stools 3yrs 

Patient was apparently alright 3years ago, then he started experiencing incomplete evacuation of stools 

He passes stools twice a day, normal in consistency

Associated with pain abdomen at night 

Relieves spontaneously 

Pain In the epigastric region and right hypochondric region 

Since 3 years and aggravted on not eating and 

Relievies on eating, drinking water and on taking medication 

Associated with bloating sensation since 1 year and burning type of chest pain(retrosternal) no radiation of pain , no sob, palpitation 

No h/o pain on defecation / straining on passing stools /blood or mucus / constpation altering with diarrhoea 

No h/o malabsorption or weight loss

PAST HISTORY

K/c/o HTN since - 1 year telmisartan 40mg amlodipine 5mg

H/o scabies since 1 year resolved now

PERSONAL HISTORY 

normal apettite and a vegetarian bowel and bladder movements are normal with a h/o 4-5 cigs / day since 20 years 

GENERAL EXAMINATION 

Patient is conscious, coherent, oriented to time place person 

no pallor,cyanosis , icterus ,clubbing,

 with vitals of 

bp:- 140/80mmhg ,

pr:- 82bpm 

grbs:- 98mg/dl

SYSTEMIC EXAMINATION 

Abdomen :- scaphoid , no tenderness present ; bowel sounds heard 

Cvs :- s1s2 heard , no murmurs 

Rs: - bae+ , no added sounds 

Cns :- HMF - intact

Diagnosis - 

INVESTIGATIONS

Hb-12.1

TLC -6,600

Platelet-1.3lakh

Blood urea- 26

Sr. Creatinine 1.1 

Na-141

K-1.3

Cl-106

2Decho- 

No RWMA no AS/MS ; Sclerotic AV

Good LV systolic function 

Diastolic dysfunction; NO PE