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Case of a 45 year old with epigastric pain

This is a case of a 45 year old male patient who came to the hospital with a chief complaint of pain in the anterior region of the chest since 10 days

HOPI

The patient complains of pain in the epigastric region since 10 days. He says it aggrevates when he's walking and relieved when he sits

The patient complains his appetite has decreased since the onset of pain. He also complains of decreased sleep. The patient has sleep disturbances because of the pain and has multiple awakenings each night as the pain is too unbearable.

He also has SOB grade 3-4 since 10 days, insidious in onset and gradually progressive. Not associated with orthopnea and PND.

The patient had decreased urine output since 10 days

The patient had fever 10 days back, associated with chills and rigor and was diagnosed with typhoid by a local RMP.

 The patient admits he hasn't complied with the medical course.

The patient complained of bilateral pedal edema since one week

He also complains of 3 episodes of vomitting since 3 days, non bilious, non blood stained and non projectile. Not associated with nausea

PAST HISTORY

Patient is a k/c/o hypertension since 17 years and is on medication,on Tab TELMA-AM

Patient also complains of gastric acidity since 16 years for which he takes pantoprazole regularly. He complains of dizziness and headache when he fails to take them.

Patient is a k/c/o chronic kidney disease since 10 years for which he's on medication

Patient is a k/c/o diabetes since 5 years and is on medication.(on GLIMI M2 and GLIMI M1)

PERSONAL HISTORY:

Diet: Mixed
Appetite: Decreased
Sleep: Decreased
Bowel and bladder: Decreased
Habits: none 

FAMILY HISTORY: 

No relevant family history


GENERAL EXAMINATION:
Patient is conscious , coherent and cooperative.
Oriented to time, place and person.
Obese


VITALS:
Temperature: afebrile 
Blood pressure: 120/60
Resp rate:25 per minute
Pulse rate : 100 BPM
SPO2: 97%

Pallor : Present
Icterus : absent
Clubbing: not present
Koilonychia: not present 
Lymphedenopathy: not present 
Edema : present in lower limbs 





SYSTEMIC EXAMINATION 

CVS - S1, S2 heard and no murmurs 
           JVP elevated

RS - BAE + , Fine crepitations heard in infra axillary areas

P/A : Soft , Non tender, no evidence of organomegaly. 

CNS : No Focal neurological deficits. 

INVESTIGATIONS:



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