A 55 year old female with cheif complaint of burning sensation in stomach since 6 days.

2 Nov , 2023

E LOG GENERAL MEDICINE 

Hi, I am G. Akshara , 6th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.

 * This is an ongoing case. I am in the process of updating and editing this ELOG aChief complaints and duration.

Chief complaints : 

A 55 year old female , resident of Gowraram , tailor by occupation , came to the OPD with chief complaints of burning sensation in the stomach associated with pain in the lower limbs ( calf mainly ) since 6 days.

 History of present illness : 

Patient was asymptomatic 30 years back, and then she developed burning sensation in the epigastric region which was 

Incidious in onset and progressive

Intermittent type

aggreviated by oily , spicy , sore foods and releived by medication.

associated with repeated belching.

She also complains of legs pain 

Dragging type of pain , intermittent type

from below the knee to ankle

increased during nights.

Also associated with tingling sensation in both the hands.

She visited local hospital and she takes Omepresol whenever she feels the burning sensation.

Also she takes calcium tablets for legs pain.

History of past illness :

No diabetes 

No hypertension 

No TB

No CAD

No epilepsy

No Asthma

Family history : 

Father had the similar problem.

Allergies : 

No allergies

Drug history : 

Omepresol once daily from 2 months.

Personal history : 

Appetite is normal

Mixed diet

Bowel and bladder habits are regular , but increased frequency of urination during nights  since 6 days.

Sleep is adequate , but decreased during legs pain.

No addictions.

PHYSICAL EXAMINATION : 

A. General Examination

Oral consent is taken.

Examined in a well lit room.

Conscious , coherent and cooperative 

Moderatly built and nourished 

Pallor is absent.

Icterus is absent.

No cyanosis

No clubbing of fingers

No lymphadenopathy

Pedal edema is absent.

Vitals : 

Temperature: afebrile

Pulse: 72 bpm

Respiration: 16/min

Blood pressure: 110/80 mm of Hg  

Spo2: 96%

PHYSICAL EXAMINATION : 

A.Cardio vascular system :

Cardiac sounds : S1 and S2

No thrills  

No murmurs

B.Respiratory system : 

Position of trachea : centre 

Breath sounds : vesicular 

No added sounds.

C.Abdomen : 

Shape of abdomen : normal

No tenderness

No palpable mass

No organomegaly