37M Dyspepsia NUD GAD 7 years Metabolic syn WB PaJR

Discharge summary:

Age/Gender

:35 Years/Male

Discharge Type

Admission Date: 29/10/2022 12:11 PM

Diagnosis

GENERALIZED ANXIETY DISORDER GAD

NUD, tinea 

Case History and Clinical Findings

35 yr male came with chief complaints of- Epigastric pain since 5 yrs

HOPI:Patient was apparently asymptomatic 5yrs ago then he developed epigastric pain he went to local hospital 5yrs ago where he was given medication and again after 4 years he presented with loin pain went to local hospital where he was diagnosed with renal calculi and now presented with epigastric pain since 1 month

,insidious in onset ,pricking type,non radiating, reduced after taking food, burning sensation after taking spicy food,relievedaftermedication.-Nofever,vomiting,,diarrhoea 

Past history:Not a known case of DM,HTN, Asthma, Epilepsy,CVA,CAD,TBPresent history:Appetite - NornalDiet-MixedSleep -AdequateBowel and bladder habits -RegularNo addictionsGeneral Examination:Patient is conscious, coherent, co-operativeWell oriented to time, place and person

Moderately built and nourished

-Nopallor,icterus,cyanosis,clubbing,pedaloedema,lymphadenopathy vitals:

pr:87bpm bp:130/80mmhg temp:98.1 rr:14cpm

Systemic Examination:

Abdominal Examination:Inspection:-Shape of abdomen - slightly distended- Umbilicis - Central-All quadrants moving equally with respiration- No scars,sinuses, engorged veins,dilated vesselsPalpation:- No local rise of temperature,no tenderness- No organomegalyAuscultation:-Bowel sounds heardCVS: S1S2 PresentRS: BAE Present,NVBS

Brief course in hospital:

35yr male came  with chief complaints of epigastric painsince 1month, insidious in onset ,pricking type,non radiating, reduced after taking food, burning sensation after taking spicy food,relieved after medication.gastro opinion was taken was advised upper gi endoscopy was done which shows non erosive antral gastritis .ortho opinion was taken advised x ray of foot and knee which appears to be normal.derma opinion was taken for hypopigmented patches, taenia cruris was diagnosed ,topical anti fungals are given,

Investigation

CBP:

HB-13.6 TLC:9,000 RBC:5.13 PLC:2.73

Treatment Given(Enter only Generic Name)

T.PAN 40MG PO/OD

LULIFINE CREAM OD

EBERNATE CREAM OD

T.TECZINE PO/OD

Advice at Discharge

T.PAN 40MG PO/OD X 5 DAYS

T.HIFENAC PO/BDX 5DAYS

T.SHELCAL PO/OD X 30DAYS

T.NEUROKIND PO/OD X 30DAYS

LULIFINE CREAM X 1WEEK AT NIGHT

EBERNATE CREAM X 1WEEK AT MORNING

Follow Up

REVIEW AT GENERAL MEDICINE OP

When to Obtain Urgent Care

 in my own language

SIGNATUREOFPATIENT/ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY

Discharge Date Date:09/11/22 Ward:MEDICALWARD

Unit:6

Recent follow up UDLC dyadic pre PaJR:

[22/06, 00:21] Pt Advocate 37M GAD NUD WB: 𝙎𝙞𝙧 𝙖𝙢𝙖𝙧 𝙋𝙚𝙩𝙚𝙧 𝙥𝙖𝙗𝙡𝙚𝙢𝙩𝙖 𝙖𝙗𝙖𝙧 𝙝𝙘𝙝𝙚 𝙩𝙖𝙞 𝙠𝙖𝙡𝙠𝙚 𝙪𝙨𝙜 𝙧𝙞𝙥𝙤𝙩 𝙠𝙤𝙧𝙗𝙤 𝙧𝙞𝙥𝙤𝙩 𝙩𝙖𝙠𝙞 𝙖𝙥𝙣𝙖𝙠𝙚 𝙥𝙖𝙩𝙝𝙖𝙗𝙤

[22/06, 14:52] BLLM: 5 bochor aager byatha ta aekhon kemon ache?

[22/06, 15:24] Pt Advocate 37M GAD NUD WB: 𝘽𝙚𝙩𝙝𝙖𝙩𝙖 𝙖𝙠𝙝𝙖𝙣 𝙣𝙚𝙞 𝙩𝙗𝙚 𝙖𝙡𝙥𝙤 𝙠𝙝𝙚𝙡𝙚𝙞 𝙥𝙚𝙩 𝙫𝙤𝙧𝙚 𝙅𝙖𝙮 𝙖𝙧 𝙨𝙘𝙞𝙙𝙞𝙩𝙞 𝙝𝙖𝙘𝙚 𝙡𝙞𝙫𝙖𝙧𝙚𝙧 𝙟𝙖𝙮𝙜𝙖𝙮 𝙝𝙖𝙡𝙠𝙖 𝙗𝙚𝙩𝙝𝙖 𝙝𝙖𝙮 𝙤 𝙩𝙤𝙮𝙡𝙚𝙩𝙚𝙧 𝙨𝙤𝙢𝙤𝙮 𝙟𝙖𝙡𝙖 𝙝𝙤𝙮

[22/06, 18:23] Pt Advocate 37M GAD NUD WB: 𝙎𝙞𝙧 𝙖𝙢𝙖𝙧 𝙪𝙨𝙜 𝙧𝙞𝙥𝙤𝙩𝙖 𝙠𝙚𝙢𝙤𝙣 𝙖𝙘𝙝𝙚

[22/06, 18:26] BLLM: USG te apnar somosya ta bojhar kotha noi

[23/06, 18:38] Pt Advocate 37M GAD NUD WB: 𝙎𝙞𝙧 𝙖𝙠𝙝𝙖𝙣 𝙖𝙢𝙖𝙧 𝙠𝙖𝙧𝙤𝙣𝙞𝙤 𝙠𝙞 𝙖𝙘𝙝𝙚

[23/06, 18:42] BLLM: Apnar jonye ekta group toiri kore debo shekhane doinondin janaben apnar khabar plate er chobi ebong ghontai ghontai ki ki korchen anekata jemon ekhane baki ra ki bhabe janacche dekhte paren 👇

[23/06, 18:53] Pt Advocate 37M GAD NUD WB: 𝙎𝙞𝙧 𝙖𝙢𝙖𝙧 𝙪𝙨𝙜 𝙧𝙞𝙥𝙤𝙩𝙖 𝙙𝙚𝙠𝙝𝙚 𝙘𝙜𝙚𝙣

[23/06, 18:57] BLLM: 👆Aagei dekhe janiyechi

[23/06, 18:58] BLLM: 👆 Gotokal ghontai ghontai sokal theke raat obdhi ki korechilen janaben ebong kone somoi byatha hoyechilo shetao janaben