30M Abdominal Bloating, SOB and Eructation after eating since 2 years

 This is an online e log book to discuss our patients deidentified health data shared after taking his or her guardian’s signed informed consent. Here we discuss our individual patient’s problems with collectors current best evident input. This e blog also reflects my patient centered online learning portfolio and your valuable inputs in the comments 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, investigation and come up with diagnosis and treatment. 

A 30 year old patient came to the OPD with 

HOPI: Patient was apparently asymptomatic 2 years ago till he developed abdominal bloating and feeling of fullness which was insidious in onset and gradually progressive 

It is associated with shortness of breath (which is also present on exertion )and eructation after meals 

There are no aggravating or relieving factors.

Negative history: no nausea, vomiting, headache, fever or trauma 

Past History: no DM, HTN, asthma, TB, thyroid, CAD or CVA 

No past surgical history 

Personal history: 

sleep: adequate

diet: mixed

appetite: normal

bowel and bladder movements: regular in frequency and volume 

Addictions: patient occasionally drinks beer

Allergies: no known allergies 

Family history: nil significant

General examination 

Pallor: nil

Icterus: nil

Cyanosis: nil

Clubbing: nil

Lymphadenopathy: nil

Oedema: nil

Vitals: 

BP: 130/70 mmhg

PR: 84bpm

RR: 20rpm