27 year old female with complaints of pain abdomen
A Case of 27 year old female patient came to casualty with complaints of pain in epigastric region.
This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.
Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This Elog also reflects my patient centered online learning portfolio.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, investigations, and come up with a diagnosis and treatment plan.
This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.
Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This Elog also reflects my patient centered online learning portfolio.
Dr. Sarbesh Mishra, Internee
A 27 year old female homemaker resident of Chouttupal came with chief complaints of pain in abdomen, nausea and vomiting
History of present illness:
Patient was apparently asymptomatic 4 days back when she developed pain in epigastric region which is insidious in onset, gradually progressive associated with nausea and vomiting. Pain is burning type with slight radiation towards both flanks(Left >> Right). She had history of eating spicy chicken curry and 2 tandoori roti just the night before the pain started, next day morning during drinking tea the pain started. She also has a h/o food intake at irregular intervals.
H/o Vomiting since 4 days (3-4 episodes/day), non projectile, non bilious, food as content (initially clear-whitish in color subsequently changed to green-yellowish).
No history of cough, chest pain, palpitations, sweating and shortness of breath.
No history of burning micturition, hematuria and fever.
Past history :
No history of Hypertension, Diabetes Mellitus, Bronchial asthma,TB , Epilepsy, thyroid disorders.
H/o 2 previous LSCS 9 and 5 years back.
Personal history:
Her appetite is normal
She takes a mixed diet
Her bowel and bladder movements are regular
Sleep is adequate
Urine output is normal
No known allergies
No known addictions
Family history:
Her husband is diagnosed with renal stones for which he is on medication and conservative management.
Menstrual history:
Menarche at 14 years of age.
Menstrual cycle 30 days cycle with 2 days of bleeding.
LMP: 10/07/2023
General examination:
Patient is conscious, coherent and coperative well built and well nourished.
Vitals:
Temperature: Afebrile
Pulse rate: 65 bpm
Respiratory rate: 16 cpm
Bp: 100/70 mmhg
Spo2: 99%in room air
O/E:
Pallor : Present
No icterus
No cyanosis
No clubbing
No koilonchya
No lymphadenopathies
No Pedal edema
Clinical Pictures:
Systematic Examination:
-CVS:
S1 and S2 are heard
No thrills and no murmurs were heard
-Respiratory:
Vesicular breath sounds heard
Trachea is in central position
No wheezing
No Dyspnoea
-Abdomen:
Scaphoid shaped abdomen
No tenderness
No palpable mass
No hernial orifices
No free fluid
Liver and spleen are not palpable
Bowel sounds are heard
-CNS:
Conscious and normal speech
Normal gait
Crainial nerves are normal
Sensory system is normal
Motor system is normal
Investigations:
Serum creatinine: 0.8
Blood urea: 14mg/dl
RBS : 84mg/dl
Albumin: 3.71
Serum Na+ :145 mEq/L
Serum K+ : 4.0 mEq/L
Serum Cl- :102 mEq/L
Hemogram:
Complete Urine Examination:
Liver Function Test:
Ultrasonography:
RT renal calculus
Multiple tiny hyperechoic foci noted in the hall bladder
Electrocardiogram:
Chest X-Ray: Normal
Referrals:
Gastroenterology referral done i/v/o epigastric pain radiating to b/l flanks. Endoscopy advised and is normal.
Urology referral done i/v/o 5mm calculus in RT kidney and adviced conservative management with plenty of water intake and restrictions on diet like reducing spinach and tomato.
Provisional Diagnosis:
This is a case of 27 year old female with ? Acute Severe Gastritis
Treatment given:
Inj. Pantop 40mg IV stat
Inj. Ondansetron 4mg IV stat
Inj. Pantop 80mg in 500ml NS slow over 6 to 8 hrs
IVF -NS and RL @75 ml/hr
Comments
Post a Comment