49 yr female with burning sensation in epigastric region since 5 months

 In 2010 she went for a routine checkup and doctor advised her for fasting lipid profile. Found her cholesterols levels were high and she started on medication tab atorvastatin 10mg

In 2010 her husband was diagnosed with cad which worried her so much and took lot of stress but eventually came out of it believing in god.

Marital life was good and they haven’t had age difference issues in their life. Her husband has anger outbursts occasionally and small quarrels on differences for example she likes to have fast food but he likes to stay healthy etc. she is very much interested to do a job but her husband had different views on it and doesn’t like girls stepping out of home and hence she remained as house wife took care of household chores and looked after family.

In 2000 she had pain abdomen was diagnosed with cholelithiasis and cholecystectomy was done.

In 2021 she lost her mother due to natural age related causes. But since it was covid time she wasn’t allowed to go near the body or was allowed to touch her for which she felt very sad

In 2023 She married of her elder daughter which made her so sad and also happy at the same time to send her to in laws home.

Had dust allergy since three years

Daily routine- usually wakes up by 7.30-8am cooks breakfast like moori,chichire,Chura and have breakfast with tea at 10am, fruit at 11am. Cooks and have lunch around 2pm rice with non veg everyday like chicken fish mutton or egg. Takes rest for 30 minutes. Wakes up and have a cup of green tea after which she goes for an evening walk for 1-2 hours for 5-6kms. Comes back home, have snacks and take rest for a while, cooks dinner and have roti around 10pm. Occasionally have very little amount of alcohol but she feels abdominal burning sensation and so she avoided it in recent times. She had a habit of eating pan after every meal.

The routine is almost the same since her marriage and wasn’t changed or affected till date.

Bowel- had constipation since long time - pass stools once in 3 days and is on herbal medicine 

COOPERATIVE 

VITALS 

TEMP- 97.6F

BP- 120/80 MMHG 

PR- 80 BPM 

RR- 18CPM 

GRBS -215 MG/DL @ 8AM

        -200MG/DL @ 2AM

        -298MG/Dl @4PM(on 15/02/23)

SYSTEMIC EXAMINATION: 

P/A : SOFT , NON TENDER 

RS: B/L AIR ENTRY PRESENT,NVBS HEARD

CVS : S1,S2 HEARD ,NO MURMURS 

CNS : HIGHER MOTOR FUNCTIONS INTACT 

A:

ACUTE GASTRITIS 

P:

* MEDITATION

*TAB.THYRONORM 75 MCG PO /OD 

*TAB.PAN 40 MG PO/BBF 

*TAB.METFORMIN GLIMIPERIDE 1000/4 

*TAB .SITAGLIPTIN METFORMIN 100/1000

*TAB.ATORVASTATIN 10 MG PO/HS

Investigations

FBS-186mg/dl

PPBS-216mg/dl

HBA1C- 7.2%

Lipid profile:

Total cholesterol - 192mg/dl

Triglycerides - 203mg/dl

HDL - 42mg/dl

LDL - 96mg/dl

VLDL - 40.6mg/dl

Thyroid profile:

T3 - 0.86 ng/ml

T4-13.03micro g/dl

TSH - 3.82 micro Iu/ml

REPORTS:

On 16/02/23

FBS:186mg/dl

HbA1c:7.2%

Sr.Creatine:0.9mg/dl

Lipid profile

Ultrasound Abdomen and Pelvis: No sonological abnormality detected