short case
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CHEIF COMPLAINTS:
Chest pain since 3 months
Bloating sensation since 1 year
Incomplete evacuation of stool since 3 years
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 3 years ago then he started expressing incomplete passage of stools. He passes stool 2times a day.no h/o hard stools complaints of lower Abdominal pain at night ,releves spontaneously during day associated with bloating sensation since 1 year and chest pain burning type (retrosternal) no radiation of pain,No sob no h/o pain on defication/ staining on passing stools /blood/mucus .No history of malabsorption or weight loss.
PAST HISTORY:
K/C/O HTN SINCE 1 YEAR ( telmisartan 40 mg OD, Amlodipine 5 mg)
H/o scabies 1 year back (resolved now)
PERSONAL HISTORY:
Diet:vegetarian
Appetite:normal
Sleep: Adequate
Bowel and bladder:normal
Micturition:normal
Habits: cigarettes since 20 years (4 to 5)
Reduced smoking since 1 year
DRUG HISTORY:
no significant history
FAMILY HISTORY:
No members of the family have similar complaints
GENERAL EXAMINATION:
Patient was concious coherent cooperative and well oriented to time place and person.
No pallor,no cyanosis,icterus, clubbing no generalized lymphadenopathy,no pedal edema
VITALS:
Temperature: afebrile
PR:72bpm
RR:16cpm
BP:120/80mm hg
SYSTEMIC EXAMINATION:
ABDOMEN:
INSPECTION:
shape-scaphoid
Flanks-free
Umbilicus-everted and central position
Hernial orifices-nornal
No dilated veins
No scars and sinuses
PALPATION:
Non tender
No Local rise of temperature
No palpable Mass
Spleen and liver not palpable
AUSCULTATION:
Bowel sounds-present
RESPIRATORY SYSTEM:
Chest is symmetrical
Trachea:central
No drooping of shoulders
No supraclavicular hollowing
No dysponea
No wheeze
CVS:
S1 S2 heard
No thrills, murmurs
CNS:
Concious
Speech normal
Gait normal
Sensory system normal
Motor system normal
PROVISIONAL DIAGNOSIS
Constipation and irritable bowel syndrome symptoms
INVESTIGATIONS
TREATMENT:
TAB : pan40mg PO OD
TAB : telmisartan 40mg + amlodipine 5 mg
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