A 29 year old female came to opd with chest pain

 OPD case

This is an online E logbook 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 an available global online community of experts to solve those patients 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 are welcome. 

29 year old female labourer by occupation came to OPD with cheif complaint of chest pain since 1 week

History of presenting illness
Patient was apparently asymptomatic 1 week ago then she developed chest pain in epigastric region which was insidious in onset,non progressive, continuous, burning type,non radiating, aggravated on work ,no releiving factors.
History of one episode of vomiting 2 days ago contents are food
History of belching is present
No h/o of nausea, abdominal pain,sob

Past history
History of similar complaints 8 months ago,then treated with sucralfate and pantop
History of laparotomy surgery 3 years ago due to small bowel obstruction

Personal history
Diet mixed
Appetite normal
Sleep altered
Bowel and bladder regular
No addictions

GENERAL. EXAMINATION

Patient is examined in a well light room after taking the consent.

Patient is conscious, coherent and cooperative, moderately built and moderately nourished.

Mild pallor is present 
There are no signs of  icterus , cyanosis , clubbing , koilonychia , lymphadenopathy.

Vitals
Temparature afebrile
BP- 110/80 mmHg
Pulse- 86 bpm regular,normal volume
RR- 18cpm

Per abdomen examination

Inspection 
Shape of abdomen scaphoid
Umbilicus inverted
Skin normal
No dilated veins
A vertical scar is present
No visible gastric paralysis

Palpation
No local rise of temperature
No tenderness
No palpable swellings

Percussion
No abnormal finding 

Auscultation
Normal Bowel sounds are heard

Respiratory system :- trachea is central, normal vesicular breath sounds heard.

CVS S1,2 heard no murmurs

CNS no focal neurological deficit

Provisional diagnosis
Epigastric pain 2° due to acid reflux?

Comments

Post a Comment

Popular posts from this blog

A 16 year old male presented with fever and epistaxis

Image
  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     A 16 year old male patient, student, was brought to casualty with chief complaints of bleeding from nose since 4 days and fever since 4 days. HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 4 days back and then he developed fever which was high grade, continuous type and associated with chills and rigors. It was relieved temporarily on medications. Patient also had bleeding from nose since 4 days, recurrent type, occurring 2-3 times per day, each episode lastin
Read more

60 year old male presented with fever and cough since 10 days

Image
  This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent . Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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 diagnosis and treatment plan. A 60-year-old male resident of ramannapeta weaver by occupation came to GM opd with chief complaints of cough for 10 days, fever since 10 days and shortness of breath since 10 days. Patient was apparently as
Read more

A 32 year old male presented with pleural effusion secondary to tuberculosis

Image
  This is an online E logbook 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 an available global online community of experts to solve those patients 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 are welcome.  Chief complaints: Fever since 1 week  Stomach pain at right side since 1 week   History of presenting illness Patient was apparently asymptomatic 1 week back then he developed fever which is sudden in onset ,continous,gradually progressive associated with chills and rigors,evening rise of temperature was present with night sweats.no aggregating factors ,temporarily relieved by medication  Patient also complained of abdpmen pain since 1 week in right hypochondriac,rt.lumbar,umbilicus region ag
Read more