A60 year old woman suffering from burning sensation on abdomen and chest since 2 year..

Patient name-- ACACIA463NILOTICA(02)

This is a HIPAA de-identified open-online-patient-record with initial information in duty-doctors notes as well as patient's voice, posted here spring 2016 after collecting informed patient consent (form downloadable here) by our patient-information-communication-executive ,managed by Dr.Madhavi.

C/O=> Burning on abdomen&  chest since  2year.
        Mouth ulceration ,constipation, acidity since  2year
      LBA since 2 Months
    Cyncope some time since 15 days..

PATIENT History in patient voice:--
         

CLINICAL IMAGES:-

A

MEDICAL HISTORY:--   not significant

SURGICAL HISTORY:-- cataract operation (Rt eye), 6Month ago.

OBS.HISTORY:--  9 P< 5M,4F, 1 Die 10 hours after birth
                          All child ND at home
                      LCB- 30 yr/ M

MENSTRUAL HISTORY:--  menopause since 16Year

FAMILY HISTORY:-- not significant

PERSONAL HISTORY:-- tobacco & supari chewing since 2Year.

NUTRITIONAL HISTORY:-- nonvagaterian.

PSYCHO-SOCIAL=>
                               -patient behavior- good
                    - family adjustments- good
                      - earning source-majduri

OBJECTIVE EXAMINATION:--

• General= skin- normal colour
                   Tongue- ulceration
                  Posture- normal
               Gait- normal & head slightly forwarded.

• Palpation= abdomen- softy & normal
                       Lower back area- no muscular spasm.
•Auscultation= chest - normal sound

• Musculo-skelatal examination=
   
Lumber ROM- all movement are normal Range of motion

Muscle tone- normal

Muscle power-- U.L& L.L all muscle power grade  5

INVESTIGATION=>
                                - CBC
                                URIN< R,M
                               - USG abdomen.

ANALYSIS= Gastric ulceration.??

PLANING=

Today advised investigation..
USG abdomen:-
.