ACID PEPTIC DISEASE DENOVO HYPERTENSION

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This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

51YR OLD MALE WITH C/O BLOOD IN STOOLS SINCE 15 DAYS

C/O PAIN ABDOMEN SINCE 15 DAYS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS ABCK THEN DEVELOPED BLOOD IN STOOLS -DAILY,PAIN EPIGASTRUIM INCREASES AFTER FOOD INTAKE ASSOCIATED WITH FLATULANCE AND DYSPEPSIA,DECREASED APETITE AND CONSTIPATION FOLLOWED BY BLOOD IN STOOLS AFTER DEFICATION

BLOOD IN STOOLS NOT ASSOCIIATED WITH PAIN

NO H/O SIMILAR COMPLAINTS IN PAST

NO H/O DM,HTN,ASTHMA,EPILEPSY,

NO H/O CKD,CLD,CAD,CVD.

PAST HISTORY

N/K/C/O DM,CVA,CAD,ASTHMA,EPILEPSY,THYROID DISORDERS

PERSONAL HISTORY

MIXED DIET

APPETITE -NORMAL

BOWEL -REGULAR

MICTURITION -NORMAL

NO KNOWN ALLERGIES

FAMILY HISTORY - NOT SIGNIFICANT

GENERAL PHYSICAL EXAMINATION

PT IS CONSCIUOUS, COHERENT, COOPERATIVE WELL ORIENTD TO TIME, PLACE, PERSON

MODERATELY BUILT AND NOURISHED

VITALS

BP : 120/80MM HG

PR 84 BPM

SPO2 98 % AT RA

TEMP 98.3 F

GRBS-130 MG/DL

NO  PALLOR , CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA

ICTERUS PRESENT

SYSTEMIC EXAMINATION

CVS S1 AND S2 +

RS NVBS HEARD, BAE +

P/A - SOFT,NON TENDER

CNS EXAMINATION:NFND

SURGERY REFERAL WA SDON EON 16/12/2023
 I/V/O BLOOD IN STOOLS SINCE 1 MONTH

DIAGNOSED AS GRADE I HAEMORROIDS

ADVICSED

TAB DAPHLON 500MG PO/OD

FIBRE RICH FOOD

PLENTY OF SAL FLUIDS

SITZ BATH WITH BETADINE /DETTOL

SYP.CREMAFFIN TID 10ML H/S /SOS

INVESTIGATION:

RFT   15-12-2023 04:46:PM     UREA   29 mg/dl 50-17 mg/dl  CREATININE   1.0 mg/dl 1.3-0.8 mg/dl  URIC ACID   5.1 mg/dl 7.2-3.5 mg/dl  CALCIUM   10.1 mg/dl 10.2-8.6 mg/dl  PHOSPHOROUS   3.8 mg/dl 4.5-2.5 mg/dl  SODIUM   139 mEq/L 145-136 mEq/L  POTASSIUM   4.1 mEq/L 5.1-3.5 mEq/L  CHLORIDE   102 mEq/L 98-107 mEq/L	LIVER FUNCTION TEST (LFT)   15-12-2023 04:46:PM     Total Bilurubin   1.29 mg/dl 1-0 mg/dl  Direct Bilurubin   0.49 mg/dl 0.2-0.0 mg/dl  SGOT(AST)   14 IU/L 35-0 IU/L  SGPT(ALT)   08 IU/L 45-0 IU/L  ALKALINE PHOSPHATE   110 IU/L 119-56 IU/L  TOTAL PROTEINS   6.9 gm/dl 8.3-6.4 gm/dl  ALBUMIN   4.37 gm/dl 4.6-3.2 gm/dl  A/G RATIO 1.73
HBsAg-RAPID   15-12-2023 04:46:PM Negative	Anti HCV Antibodies - RAPID   15-12-2023 04:46:PM Non Reactive

2D ECHO: MILD AR REIVIAL MR/ TR

NO RWMA, NO AS/MS, SCLEROTIC AV 

GOOD LV SYSTOLIC FUNCTION

DIAGNOSIS:

ACID PEPTIC DISEASE

DENOVO HYPERTENSION

TREATMENT:

TAB CLINIDIPINE 10MG OD

TAB PAN 40MG OD

TAB HYDROCHLORTHIAZIDE 12.5MG OD

SYP SUCRALFATE 10ML TID 10ML

TAB PCM 650MG TID

TAB CEFIXIM 200MG BD

TAB NYROBION FORTE OD

ADVICE AT TREATMENT

TAB CLINIDIPINE 10MG OD X 10 DAYS

TAB PAN 40MG OD X 10 DAYS

TAB HYDROCHLORTHIAZIDE 12.5MG OD X 10 DAYS

SYP SUCRALFATE 10ML TID 10ML X 10 DAYS

TAB PCM 650MG TID X 10 DAYS

TAB CEFIXIM 200MG BD X 10 DAYS

TAB NYROBION FORTE OD X 10 DAYS