A 70 year old male with epigastric pain
July 27,2023
Hi,I am Athram Divya Sri 5th semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio.
CASE SHEET
CHIEF COMPLAINTS:
A 70 year old male Patient came to the casualty with c/o epigastric pain
HOPI:-
Patient was apparently asymptomatic since 3 days. He then developed epigastric pain which was insidious in onset and gradually progressive,non-radiating,squeezing type of pain.
Not associated with nausea, vomittings,chest pain, palpitations,SOB.
C/O giddiness,sweating,decreased appetite since 3days
No C/O constipation/ loose stools
C/O fever since 2days - low grade, intermittent associated with chills and rigors, relieved by medication.
C/O burning micturition since 10days which is not associated with abdominal pain
No C/O decreased urine output, pedal edena , facial puffiness
PAST HISTORY:-
No h/o similar complaints in the past
Not a k/c/o DM,HTN,TB, EPILEPSY, CVA,CAD, THYROID DISORDERS, BRONCHIAL ASTHMA.
PERSONAL HISTORY -
mixed diet
Normal appetite
Regular Bowel and Bladder movements
Sleep -adequate
No allergies
addictions- Daily toddy consumer since 30years. Tobacco smoking stopped 20yrs back.
FAMILIES HISTORY:
No significant family history
GENERAL EXAMINATION
Patient is conscious coherent and cooperative
No signs of pallor, icterus, cyanosis, clubbing ,lymphadenopathy and pedal edema
