General Medicine Blog-6

March 27, 2022

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

A 32 year old female patient, resident of Parada, Farmarette by occupation, came to our hospital with chief complaint of stomach pain.

Date of Admission:-26/03/2022

History of present illness:-
Patient was apparently asymptomatic 10 days back and developed pain in the right epigastric region radiating to the right hypochondrium and right lumbar region which was sudden in onset, gradually progressive with no aggrevating and relieving factors.

History of past illness:-
Not a known case of diabetes, hypertension, tb, epilepsy.

Personal history:-
Patient has normal eating habit with mixed diet.
Takes toddy occasionally.

Daily routine:-
Patient used to wake up at 6.00AM , takes breakfast in between 8.00AM-9.00AM. Then she goes to farm, and takes rice in between 1.00PM-2.00PM and dinner at 8.00PM and goes to bed by 10.00PM.

Family history:-
No significant family history.

General examination:-
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
No pallor
No icterus
No clubbing
No Lymphadenopathy

Vitals:-
Temperature-99 F
Pulse rate-80 bpm
RR-20 cpm
BP-120/100 mmhg
SPO2-96% at room temperature
RBS-109mg/dl



Investigations:-
LFT
RFT
RBS
CBP
ECG
BLEEDING TIME AND CLOTTING TIME
CUE

Provisional diagnosis:-
Cholelithiasis

Treatment:-
Tab. MVT × OD 
Surgery suggested.

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