General Medicine Blog-10

November 16, 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 Nalgonda, vegetable seller by occupation, came to our hospital with chief complaint of pain in right side of upper abdomen.

Date of Admission:-14/11/2022

History of present illness:-
Patient was apparently asymptomatic 15 days back until she developed pain in the right side of hypochondrium which was insidious in onset and there are no aggravating and relieving factors. Bowel and bladder movements are normal.

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

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

Daily routine:-
Patient used to wake up at 5.00AM , goes to work at 7.00AM, takes breakfast in between 9.00AM-10.00AM. Then she continues her work, takes rice in between 2.00PM-3.00PM, dinner at 9.00PM 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.
Pallor present
No icterus
No clubbing
No Lymphadenopathy

Vitals:-
Temperature-98 F
Pulse rate-70 bpm
RR-16 cpm
BP-120/80 mmhg
SPO2-96% at room temperature
RBS-83 mg/dl

Systemic examination:- 
CVS- Cardiac sounds-S1, S2 normal
        - No thrills ,Cardiac murmurs
Respiratory system- Normal
Abdomen-shape of abdomen- Scaphoid 
                 - No Tenderness 
                 - No palpable mass 
                 - Liver, Spleen not palpable 
CNS- Speech- normal 
        - Concious 

Provisional Diagnosis:-
Cholilithiasis

Investigations:-
CUE
Prothrombin time
Uric acid serum
Blood urea
RBS
LFT
Serum creatinine
Serum electrolytes and Serum Ionized Calcium
Bleeding and Clotting time
APTT
ECG



Treatment:-
IV Fluids @ 100ml/hr
Inj. Tramadol 1amp in 100ml × IV × BD
Tab. Pan 40mg × OD
Inj. Zofer 4mg × SOS
Tab. Paracetamol 650mg × TID


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