63 years old male with constipation and incomplete inacuvation of stools

17th January 23
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input
63 year old male patient labor by occupation resident of nalgonda came to OPD 

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 
 IBS symptoms 
PROVISIONAL DIAGNOSIS 
Constipation and irritable bowel syndrome symptoms 
INVESTIGATIONS 
TREATMENT:
TAB : pan40mg PO OD
TAB : telmisartan 40mg + amlodipine 5 mg 


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