Gastritis case

General Medicine E-log

A 70 year old male presented to the OPD with complaints of burning chest pain since 2 years and fatigue since 2-3 years.

Chief Complaints: 

A 70 year old male, resident of came to the OPD with complaints of fatigue since 2-3, burning chest pain since 2 years and urinary incontinence since 1 year.

History of presenting illness:

Patient was apparently asymptomatic 2 years ago when he developed chest pain which was insidious in onset, intermittent, non progressive. It is aggregated by eating food. No relieving factors.

He has fatigue and weakness since 3 years.

Patient also has complaints of urinary incontinence since 1 year with was not associated with fever, burning micturition or painful voiding.

Past history:

History of 

TB 12 years ago

HTN since 10 years

N/K/C/O DM, asthma, epilepsy, CAD or CVA

Personal history:

Diet: mixed

Appetite: reduced 

Sleep: adequate

Bowel and bladder: urinary incontinence since 1 year

No know allergies or addictions.

Family history:

Not significant

General Examination:

Patient is conscious, coherent and cooperative

No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy or pedal oedema is seen.

Vitals:

Temperature: afebrile

RR: 28 cpm

PR: 82bpm

BP: 120/90 mmHg

Systemic Examination:

CNS:

Speech: normal
No signs of meningeal irritation
Motor & sensory system: normal
Cranial nerves: intact

CVS:

S1, S2 were heard

No Murmurs
No thrills

Respiratory system:
Position of Trachea: central
BAE: present
NVBS heard
Crepitus heard on left side

Per Abdomen:
Rigid, non tender, no organomegaly 
Hernial orifices are normal
No palpable masses

Bowel sounds were heard

Provisional diagnosis: 

Investigations:

                                       ECG

Final diagnosis: 

Treatment given (present course in the hospital):

01/08/23

1. Tab. PANTOP 40 mg PO/OD

2. Tab. NEUROBIN FORTE PO/OD