https://pavankumar114.blogspot.com/2021/10/51-year-old-male-farmer-came-with-co.html?m=1

51 year old male farmer came with c/o 

Dyspepsia (Burning sensation in throat chest&epigastric region) since 15 yrs

Abdominal discomfort & loose stools since 15 yrs


HOPI:

C/o dyspepsia (Burning sensation in throat chest&epigastric region) since 15 yrs (2006) after intake of meat/egg/milk

C/o abdominal discomfort since 15 yrs (2006) after intake of meat/egg/milk which was releived with passage of watery stool after few hours of food intake.

Tenesmus+

No h/o blood/mucus in stools

No h/o pain abdomen/vomiting/fever

C/o itching in groin region since 2 years

C/o itching in axilla , flexural aspects of knee & left cheek since 3 months

No other complaints


Past history:

No h/o DM/HTN/Asthma/Epilepsy/CAD/TB


Marital history:

In 1996 at the age of 21 patient had disturbed sleep and abnormal behavior at night time (sexual thoughts) which were observed by his father and was immediately got married

3 children (1 daughter & 2 sons)


Personal history:

Diet: Mixed

Sleep: Adequate

Bowel: Loose stools

Bladder: Regular

Addictions: Gutka chewer


O/E:

Pt c/c/c

Moderately built & nourished

No pallor/icterus/cyanosis/clubbing/koilonychia/ generalized lymphadenopathy/pedal edema





Tinea corporis et cruris





Tinea corporis et faciei


Temperature : 98.6 F

BP : 110/70 mm Hg

PR : 72 bpm , regular

CVS : S1 S2 +, no murmur

RS : BAE+ , NVBS +

P/A : soft, non tender

CNS : NFND


Investigations:








RBS: 152 mg/dl
Serology: Negative

Event timeline



Provisional diagnosis:Non ulcer dyspepsia      ?IBS
Tinea corporis et cruris et faciei

Treatment:

1. Tab.PAN40 mg PO/OD
2. Syp.sucralfate 10ml PO/TIDm
3. Tab.MVT PO/OD
4. ORS sachets 1 in 1 litre water - 200 ml after each episode of loose stool
5. LULIFIN cream L/A BD
6. ATARAX anti itch lotion L/A BD
7. Tab.ATARAX 10mg PO H/S
8. Monitor vitals

Discharge summary:
Discharge Date
Date:2/10/2021
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.HAREEN (SR)
DR.RAKESH BISWAS (HOD)
Diagnosis
Non ulcer dyspepsia
?IBS
TINEA CORPORIS ET CRURIS ET FACIEI
Case History and Clinical Findings


Investigations
51 year old male farmer came to opd with c/oDyspepsia (Burning sensation in throat chest&epigastric
region) since 15 yrsAbdominal discomfort &loose stools since 15 yrsHOPI:C/o dyspepsia (Burning
sensation in throat chest&epigastric region) since 15 yrs (2006) after intake of meat/egg/milkC/o
abdominal discomfort since 15 yrs (2006) after intake of meat/egg/milk which was releived with
passage of watery stool after few hours of food intake.Tenesmus+No h/o blood/mucus in stoolsNo h/o
pain abdomen/vomiting/feverC/o itching in groin region since 2 yearsC/o itching in axilla , flexural
aspects of knee &left cheek since 3 monthsNo other complaintsPast history:No h/o
DM/HTN/Asthma/Epilepsy/CAD/TBMarital history:In 1996 at the age of 21 patient had disturbed sleep
and abnormal behavior at night time (sexual thoughts) which were observed by his father and was
immediately got married3 children (1 daughter &2 sons)Personal history:Diet: MixedSleep:
AdequateBowel: Loose stoolsBladder: RegularAddictions: Gutka chewerO/E:Pt c/c/cModerately built
&nourishedNo pallor/icterus/cyanosis/clubbing/koilonychia/ generalized lymphadenopathy/pedal
edemaTemperature : 98.6 FBP : 110/70 mm HgPR : 72 bpm , regularCVS : S1 S2 +, no murmurRS :
BAE+ , NVBS +P/A : soft, non tenderCNS : NFND
Investigation
RBS: 152 mg/dlSerology: Negative
 Name Value Range Name Value Range
BLOOD UREA 30-
09-2021 09:19:AM
20 mg/dl 42-12 mg/dl SERUM
CREATININE 30-09-
2021 09:19:AM
1.2 mg/dl 1.1-0.6 mg/dl
 SERUM ELECTROLYTES (Na, K, C l) 30-09-2021 09:19:AM
 SODIUM 143 mEq/L 145-136 mEq/L
 POTASSIUM 4.2 mEq/L 5.1-3.5 mEq/L
 CHLORIDE 101 mEq/L 98-107 mEq/L
 LIVER FUNCTION TEST (LFT) 30-09-2021 09:19:AM
 Total Bilurubin 0.96 mg/dl 1-0 mg/dl
 Direct Bilurubin 0.20 mg/dl 0.2-0.0 mg/dl
 SGOT(AST) 29 IU/L 31-0 IU/L
 SGPT(ALT) 24 IU/L 34-0 IU/L
 ALKALINE
PHOSPHATE
76 IU/L 98-42 IU/L
 TOTAL PROTEINS 6.2 gm/dl 8.3-6.4 gm/dl
 ALBUMIN 4.2 gm/dl 5.2-3.5 gm/dl
 A/G RATIO 1.12
Anti HCV Antibodies
- RAPID 30-09-2021
09:19:AM
Non Reactive Kit
Name:Life Band
HBsAg-RAPID 30-
09-2021 09:19:AM
Negative Kit Name:
Virucheck
Treatment given
Treatment:1. Tab.PAN40 mg PO/OD2. Syp.sucralfate 10ml PO/TIDm3. 
Tab.MVT PO/OD4. 
ORSsachets 1 in 1 litre water - 200 ml after each episode of loose stool5. 
LULIFIN cream L/A BD6.
ATARAX anti itch lotion L/A BD7. 
Tab.ATARAX 10mg PO H/S8. 
Monitor vitals


Advice at Discharge
Treatment:1. Tab.PAN40 mg PO/OD2. Syp.sucralfate 10ml PO/TIDm3. Tab.MVT PO/OD4. ORS
sachets 1 in 1 litre water - 200 ml after each episode of loose stool5. LULIFIN cream L/A BD6.
ATARAX anti itch lotion L/A BD7. Tab.ATARAX 10mg PO H/S8. UPPER GI ENDOSCOPY
Follow Up
REVIEW AFTER 2 DAYS TO MEDICINE OPD WITH UGIE REPORT
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:
 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

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