Thursday, 25 February 2016

50yr old man with chest pain since 6month

Name- xxxx
Age/sex- 50/male
Occupation- labour pt
Religion- Hindu
Add-- .....xxx

Present complain- chest pain and BP increase problem before since 4-6 months ago ...vomiting occasionally ..chest burning on vomiting and burning relieved after vomiting ..epigastric discomfort since 4-6 months and joint pain since 8 days ago ..patient feel weakness and easily fatigue on exertion.

Tongue- white coated
Thrist - normal
Apetetite- normal
Urine- normal
Stool- normal
Smoke- bidi occasionally
Tobacco chewing - occasionally
BP- 120/65 mg/hg
Pulse- 70/min
RR- 21/min

Past history - before 3 years patient have the fracture of head of left femur ..then surgery in hospital and patient get well in 1 month ..and before 1 month ago patient was suffering from lower limb pain and easily fatigue on least exertion ..chest burning pain ..epigastric discomfort when chest burning and chest burning is continuous ..joint pain Bcozz of weakness feeling ...

Investigation- LFT/RFT
                   CBC
            Urine RM
         Lipid profile

Treatment- tab. Emiset - BD
                Tab. Pantop 40 ..BD

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