A 37 year old male with fullness of abdomen since 2 years.

 July 6,2022

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CASE:

A 37 yrs old male bussiness man by occupation came with the chief complaints of fullness of abdomen since 2 years.

HISTORY OF PRESENTING COMPLAINTS:

Patient was apparently asymptomatic 2 yrs back and then he developed this feeling of abdominal fullness and epigastric discomfort after meal,he also complained of belching and burning sensation in the throat and retrosternal region after consuming spicy and fast food for which he takes antacids everyday to get relief.Sometimes when he consumes spicy food, he takes antacids when they do not provide relief,he induces vomiting as there is pain and burning sensation in the chest and epigastric region.Sometimes he complaints of heaviness in the chest.

DAILY ROUTINE:

He wakes up in the morning around 8 to 9 AM.He takes his antacids and has his breakfast.he goes to work(he owns a grocery store) at around 10 AM and returns home to have his lunch between 2-4 PM and rests for an hour.In the evening he has tea and snacks and goes back to his work.At night he returns home at 10 PM and has dinner and goes to bed around 12 AM. 

Occasionally,in the morning before breakfast he takes an antacid and takes his other medicaton(anti-hypertensives),he feels bloated and for relief he takes another antacid.

PAST HISTORY:

Patient is known case of hypertension since 2012.He was diagnosed with hypertension through routine medical check up and since then he has been on anti-hypertensives.

In 2015 he had pain in the chest for which he went to the local hospital and was diagnosed with myocardial infarction.

In 2016 he had met with an accident for which he had fracture in the humerus and was on rest for 2 months.

from 2015-2017 he received treatment for hypertension from local hospital,from 2017 till date he has been visiting another hospital for his treatment and regular check ups.

In 2021 September, the doctors had decided to do percutaneous transluminal coronary angioplasty(PTCA) to the patient.

PERSONAL HISTORY:

Diet:mixed diet; sleep:adequate; bowel and bladder:regular ; Apetite:patients feels hungry but he scared to eat due to bloating ;Addictions:patient has a history of smoking for 10-15 years(6-7 cigarette per day).He used to occasionally drinks alcohol during parties.Patient has completely stopped smoking and drinking since 9 months after his PTCA.

FAMILY HISTORY:

Patients father has a history of hypertension and has undergone bypass surgery.His father also has history of bloating and belching.

GENERAL EXAMINATION:

Pallor:present

Icterus:absent

Cyanosis:absent

Clubbing:absent

Lymphadenopathy:absent

pedal edema: absent

VITALS:

Temp: afebrile

Pulse; 76 beats per min

BP: 110/80 mm of hg

RR:15 BPM 

SYSTEMIC EXAMINATION:

CVS:s1 and s2 are heard

CNS:no focal neurological deficits 

ABDOMEN:distended abdomen ,soft and non tender

RS:bilateral vesicular breath sounds are heard

 INVESTIGATIONS:

PROVISIONAL DIAGNOSIS: 

Non ulcer dyspepsia with history of PTCA

TREATMENT:

tab.Clopilet(twice daily for 3 mon and after 3 mon once daily)

tab.Supermet 25 mg 

tab.Atocor 40mg OD

tab.Telmikind 40mg OD

tab.Sorbitrate 5mg.