22/M Epigastric Pain

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I've 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 a diagnosis and treatment plan

                                  CASE

 A 22 year old male born in 19/1/2001 ,resident of Coochbehar,presented with complaints of Pain abdomen since 12 Years

Patient was apparently asymptomatic till 10 years of age,after which he started developing abdominal pain,in the epigastric region,insidious in onset, gradually progressive,burning type,non radiating ,associated with early satiety ,fullness and indigestion , increased on consumption of fried food like fish and aloo and decreased on intake of soft diet and medication,not associated with nausea,Vomiting,regurgitation of food,loose stools 

H/o difficulty in sleeping at nights due to abdominal discomfort 

In 2018,he started working as a food service boy in a catering company and had to attend multiple events at different times in a day and due to which he didn’t have adequate sleep and food at times and his symptoms increased further

He observed these symptoms more with consumption of Prawns ,after which he stopped taking it.

Personal History:

Born in 10/1/2001

Completed schooling in 2015

Studied BA(Arts) 

Currently learning excel and coding ,also looking after the  works in his fathers cloth store 

No H/o smoking and alcohol consumption 

Dietary History:

INPUT: 

Morning-

Badam and chole followed by 1 cup puffed rice with mirchi and onion with cup of black coffee or tea

Afternoon-

2cups Rice with Dal ,curry (occasionally fish)

Evening-

Milk coffee with puffed rice 

Night- 2 cups Rice and 1 curry

Family History:

4 members in the family

He resides with his father,mother and a younger brother 

No H/o any health issues in the family 

Treatment History:

He had two medical consultations in the past for the same complaints and his symptoms resolved on taking medication(PPI’s) but he developed the same complaints once he stopped taking the medication 

Gastroenterology consultation was taken on 2/5/23 i/v/o the same above complaints and endoscopy was showed a normal esophagus, stomach and D1,D2 of duodenum and was prescribed with Tab Rifagut 200 mg ,Cap Veloz-D,and syp gelusil-ls

https://photos.app.goo.gl/qwP2UCDjEroVNv1f6

O/E:

Moderately built and nourished

Prematuring Greying of Hair is present -which may indicate nutritional deficiency 

Pallor-Absent

No cyanosis and icterus

Per Abdomen Examination:

Soft ,Non tender

Bowel sounds-Heard

CVS-S1,S2 heard ,No murmurs

RS-B/L air entry present, Normal vesicular breath sounds heard

CNS-No focal deficits 

Investigations :

Hemogram-

Upper GI Endoscopy-

Ecg-