50yr old female with abdominal distention
September 1st ,2022
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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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 a diagnosis and treatment plan.
50yr old female patient came to the casuality yesterday with chief complaints of
Pain abdomen since 3days
Vomitings since 3days
Abdominal distention since 2days
HOPI:
Patient was apparently asymptomatic 3days ago then she went to RMP for constipation and milk of magnesia was given later after taking it she developed pain in abdomen which is diffuse and is of squeezing type and passed loose stools for 20 to 30times
H/o vomitings since 3days 1episode per day, non bilious,non projectile and food as contents.
H/o abdominal distention since 2days
No h/o fever, burning micturition.
Past history:
Patient attempted suicide 15yrs back by drinking poison and patient got admitted in our hospital for 2months .
She was chronic alcoholic since 4years and since 3years patient eats mud everyday when she drinks alcohol from then she had got similar complaints in the past since 3years and visited hospital for multiple times and medication was used to pass stools.
Not a k/c/o DM,HTN,TB,CAD, EPILEPSY
Surgical h/o: Patient underwent tubectomy 25years ago.
Personal history:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowels: regular
Micturition: Normal
Addictions:Chronic alcoholic since 4years
Family history:
Not significant
General examination:
Patient is c/c/c
Vitals:
Afebrile
Bp: 110/60mmhg
PR: 102bpm
RR: 21cpm
Pallor present
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No edema
Systemic examination:
CVS: S1 S2 sounds heard
RS: BAE+,clear
P/A :Soft and non tender
CNS:NAD
Chest x-ray at admission
At admission
On 01/09/2022 morning
