case history

CASE HISTORY

March 11,2022


March 08,2022

"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 patients clinical problems with collective current based inputs.

CHEIF COMPLAINT:

22Y/F  and dayworker by occupation came to OPD with pain in Right upper abdomen since 2 months with history of vomiting and constipation 

HISTORY OF PRESENT ILLNESS:

Patient was apparently assymptomatic two months ago after she developed pain in right upper portion of abdomen ,sudden and intensifting pain ,and vomitings  after food intake i.e food as content relived after taking medication c/o mild pain in upper abdomen intermittent ,radiating to upper back c/o hard stools.

HISTORY OF PAST ILLNESS:

No H/O similar complaints in the past
H/O cardiac surgery in childhood.septal wall defect repair? 
not a K/ C/O DM; HTN; TB ; ASTHMA;epilepsy ;thyroid abnormalities

PERSONAL HISTORY:

Diet: mixed
appetite:normal
sleep: adequate
bladder movements: irregular

FAMILY HISTORY:

No similar history in family

GENERAL EXAMINATION: 
patient is conscious, coherent and cooperative at the time of joining
-no pallor

- no icterus

- no lymphadenopathy

-no cyanosis

-no clubbing of fingers

- no edema of feet

- no malnutrition 

-no dehydration

VITALS:
-Temp:98.3f

-Pulse rate: 70bpm

-Respiration: 16 cpm

-BP: 120/80 mmhg

-SPO : 99%

SYSTEMIC EXAMINATION:

CVS 
- no thrills

- no cardiac murmers

- S1&S2 sounds are heard

RESPIRATORY SYSTEM:

.BAE present 

CNS

HMF intact

INVESTIGATION: 
Surgical profile;
DIAGNOSIS:
-cholelithiasis

TREATMENT:

-inj.PIPTAZ 45mg  BD

-Tab.PAN40mg BD

-Tab.POLO 650mg TD

-TAb.OROFER-XT PO/OD


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