Galib Hossain, a 25-year-old male, presented with 5 days of upper abdominal pain and 2 days of nausea and vomiting. He reported a history of NSAID use for 2 months and smoking. Examination found epigastric tenderness. Laboratory tests confirmed peptic ulcer disease caused by H. pylori infection, with a duodenal ulcer seen on endoscopy.

1. CASE PRESENTATION ON
PEPTIC ULCER DISEASE
Presented By:
Tareq Hasan Emon
Abdullah Al Mamun

2. Particulars of the patient:
Name of the patient: Galib Hossain
Age: 25 years
Sex: Male
Religion: lslam
Marital status: Married
Present address: Green Road, Dhaka
Permanent address: Rupgonj, Narayonganj.
 Name of Hospital: Green Life Medical College, Dhaka.
Date of admission: 23.02.23
Date of examination: 23.02.23

3. Chief Complaints:
Pain in upper abdomen for 5 days
 Nausea,Vomiting for 02 days

4. History of Present illness:
According to the patient, he was reasonably well 5 days back, after that he
developed pain in the upper abdomen, which was burning in nature, severe in
intensity, gradual in onset, non-radiating and relived after taking meal.Then he
developed vomiting for 2 times for 2 days which was non projectile, contained food
particles,, non-bile stained, watery and sour in taste, not associated with blood. He
also complains of loss of appetite for the last two weeks There is no history of
passage of blood in stool. His bladder and bowel habit is normal. He is normotensive
& non-diabetic.

5. History of past illness: Nothing significant
Drug history: History of taking NSAIDs for 2 months
Allergic history: He was not known to be allergic to any food or drugs
Family history: Nothing significant
Personal history: He has a history of smoking for 2 years (23 packs per year)
Immunization history: He has received 3 doses of COVID-19 vaccine
Socioeconomic history: Belongs to lower middle class family
Travel history: Nothing significant

7. Appearance: Ill looking
Body build: Average
Cooperation: Cooperative
Decubitus: On choice
Anaemia: Nil
Jaundice: Nil
Cyanosis: Nil
Koilonychia: Nil
Leukonychia: Nil
Clubbing: Nil
Oedema: Nil
Dehydration: Nil
Pulse: 82 beats/min
Blood pressure: 120/80 mm Hg
Temperature: 98°F
Respiratory rate: 16 breaths/min
Lymph nodes: Not palpable
Thyroid gland: Not palpable
Skin condition: Normal
The patient had a cannula in situ in the
dorsum of his left hand

9. Alimentary System:
Inspection:
Shape of the abdomen: Scaphoid
 Umbilicus: Inverted
Flanks are not full
Hair distribution is normal
No visible pulsation
No pigmentation & scar mark
No engorged vein

10. PALPATION:
Superficial:Tenderness in epigastric region
Deep: No organomegaly
Percussion:
Tympanic
Shifting dullness is absent
Auscultation:
Bowel sound absence

11. Cardiovascular system examination:
Nothing significant
Respiratory system examination:
Nothing significant
Central nervous system examination:
Nothing significant

12.  Salient features
My patient Galib Hossain, 25 years old male, got admitted to Green Life Medical
College and Hospital with the complaints of pain in upper abdomen for 5 days,
which was burning in nature, severe in intensity, gradual in onset, non-radiating and
relived after taking meal.Then for last 2 days, he developed non projectile vomiting
for 2 times, which contained food particles, non-bile stained, watery and sour in taste
and not associated with blood. He also complains of loss of appetite. He is non
diabetics & normotensive. He had drug history of taking NSAIDs for 2 months and he
is a smoker for the last 2 years. On Examination of the alimentary system their was
tenderness found in the epigastric region of the abdomen. All other systemic
examination was normal.

13. Provisional Diagnosis:
PUD
D/D:
Acute Gastritis
Recurrent Appendicitis

15. LABORATORY INVESTIGATIONS
 CBC- Normal
USG of Whole Abdomen – Nothing significant
Upper GIT Endoscopy
-The ulcer was visualize in the first part of duodenum.
Urea Breath test
-Positive
Rapid urease test
-Positive
Serum antibody test
-Positive against H. pylori

16.  Confirmatory Diagnosis:
PUD (Duodenal ulcer)