A 63 year old male with abdominal pain

Final exam short case..
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current based inputs.

Chief complaints:
  A 63 yr old male  cloth merchant by occupation of Bengal residence came  with c/o Right Upper abdominal painsince  3months 
History of present illness: Patient was apparently asymptomatic 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  and heart burn since 1 year 
 h/o pain on defecation / straining on passing stools 
no constipation altering with diarrhoea 
No h/o  weight loss
HISTORY OF PAST ILLNESS
K/c/o HTN since - 1 year 
telmisartan 40mg
 amlodipine 5mg
PERSONAL HISTORY 
Diet - vegetarian
Appetite - Normal 
Sleep - Adequate 
Micturition-normal
Bowel and bladder movements-Irregual
Addictions  - smokes cigarette full pack since 25 years
General Examination 
Patient is conscious, coherent, cooperative & well  oriented to time place
no pallor,cyanosis , icterus ,clubbing, lymphadenopathy 
 Vitals
Temp:  afebrile
bp:- 140/80mmhg ,
pr:- 82bpm 
grbs:- 98mg/dl
Rr:22/min
Systemic examination 
Cvs:- s1s2 heard , no murmurs 
Respiratory system- no dyspnoea,no wheeze
Abdomen:-

Inspection 

Shape of abdomen: scaphoid 

Flanks : no flanks 

No visible sinuses and scars are seen 

PALPATION

Palpation done in supine position 

Nolocal rise in  temperature 

no tenderness

No palpable mass

No rigidity Is felt 

Liver and spleen not palpable 


Percussion 

No fluid thrill

no shifting dullness

Auscultation

Bowel sounds are heard

CNS : conscious ,coherent,cooperative
Sensory and motor system are normal
No neurological defects seen

Provisional diagnosis: multiple antral  Gastric ulcer
Investigations 
Complete blood picture
Hb-12.1
TLC -6,600
Platelet-1.3lakh

Blood urea- 26
Sr. Creatinine 1.1 
Na-141
K-1.3
Cl-106
Ultrasound abdomen
UGIE - upper gastro intestinal endoscopy
Treatment:

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