A 36 year old female resident of Thirumalagiri, farmer by occupation came with chief complainta of pain abdomen and 1 episode of vomiting associated with blood

20,April 2023

E LOG GENERAL MEDICINE 

Hi, I am Nandini, 5th Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”


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. 

CHIEF COMPLAINTS:
Patient presented with complaints of stomach pain, vomitings and last episode of vomiting was associated with blood. 

HISTORY OF PRESENT ILLNESS:
She was asymptomatic 1 month ago. She had pain in upper abdomen (epigastrium) the pain decreased after vomiting. Pain was aggravating and relieved after vomiting, no radiating pain, pain was occasional and pIn increased on eating spicy food. 
Vomiting was non projectile, non bilious, food as it's content . She had approx 10 episodes of vomiting in a month. Yesterday (19/4/23) had 1 episode of vomiting with blood dark brown color. 

NEGATIVE HISTORY:
No history of fever, bloating, constipation, sob, loose stools, cough, chest pain. 

MENUSTRAL HISTORY:
Marriage at 12 yrs, menarch at 13 yrs . 
1st pregnancy at 15 yrs
Cycle 30/5-8pads/cycle no clots, no White discharge. 
obstetrics history:3 children 1st boy-20yrs
2nd girl-16yrs
3rd boy-14 yrs. 
All three lscs. 
PAST HISTORY:
3 LSCS. 
No history of tuberculosis, epilepsy,asthma,CAD.
She was diagnosed with kidney stones and relieved on medication (11 years ago). 
2 months ago small stone was observed it was resolved and passed in urine when observed in ct scan. 


PERSONAL HISTORY:
Diet: mixed(But consumes only mutton but not         
         chicken and egg)
Appetite: normal
Bowels : regular 
Bladder: regular
Sleep : adequate
Addictions: toddy occasionally
Burning Micturition earlier now normal. 
FAMILY HISTORY:
No family history

ALLERGIC HISTORY:
Food allergy for fish, brinjal, Gongura. 
Itching and prurities were seen due to consumption of above food

GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative.
Pallor is absent.
Icterus is absent.
No edema.

 
   

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