36 year old women with pain abdomen and vomiting


A 36 year old woman, farmer by occupation, resident of Tirumalagiri came to medicine OPD with chief complaints of
Pain abdomen since 1 month
Blood in vomiting 1 episode 1 day ago
History of Present illness-
The patient was apparently asymptomatic 1 month ago and then she developed, pain in the epigastric region, which is of squeezing type, aggravated on consumption of spicy, sour and non-vegetarian foods, sometimes relieved after an episode of vomiting. It is non radiating and no migration of pain. There’s is no positional variation.
She had had over 10 episodes of vomiting, in the last 1 month which is non projectile, non bilious and food as it’s content. Sometimes, early morning retching, induced vomiting. A day ago, she had an episode of vomiting with some blood which is dark brown in colour.
No h/o fever, blotting, constipation, loose stools, cough, shortness of breath, chest pain. No retrosternal burning.
Menstrual history-
Menarche at the age of 13 years
Marriage at the age of 12 years
30 days/ 5
8 pads per cycle
Obstetric History- 3 children
1st boy,by LSCS , now 20 years old
2nd female, by LSCS, now 16 years old
3rd boy, by LSCS, now 14 years old
Tubectomy done immediately after last delivery
Past History-
11 years old, Renal Calculi which was resolved on medication
2 months ago she was diagnosed with renal caliculi, which was reported resolved in the ultrasound scan a day ago
N/k/c/o HTN, DM, TB, Asthma, CAD, Thyroid, Epilepsy
Family History- no significant family history
Personal History
Married
Diet mixed
Appetite normal
Sleep adequate
Bowel and bladder movements regular
Addictions- 250 ml toddy occasionally
Food allergy to gongura, fish and brinjal which was found out 1 year ago after having mild rashes anywhere any body especially hands
Physical examination -
The patient is conscious, cooperative and coherent
Well oriented with time, place and person
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No pedal oedema

Comments

Post a Comment

Popular posts from this blog

A,40 year old male patient came to general medicine OPD with chief complaints of decreased urine output

Image
3-1-23 Hi, I am kalpak Mawale  of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio. The patient’s consent was taken verbally prior to history taking and examination of her condition.  40 year old male patient who is an advocate came to general medicine with cheif complaints of decreased urine output since 8 days. HISTORY OF PRESENT ILLNESS Patient was apparently asymptomatic 5years back then developed decreased urine output since 8 days and underwent dialysis at out hospital Sai sanjeevini .He had Renal tubular acidosis and right hip joint fracture. HISTORY OF PAST ILLNESS   Chronic kidney disease on maintenance heamodialysis since 11 years,hypertension since 5 years . No history epilepsy,TB,asthma ,diabetes,CAD. Surgical history-right hip joint surgery 10 days back. FAMILY HISTORY - no relevant family history PERSONAL HISTORY Di
Read more

A 35 year old man with hypo-pigmented patches

Image
A 35 year old married man, working as a tractor driver, resident of Bhongir came to medicine OPD with Chief complaints of increase in size of the discolouration of skin since 8 months History of Present Illness- The patient was apparently asymptomatic 8 months ago and suddenly noticed heat rashes over the nose area. It was not itchy. The rash persisted for 15 days. The skin started peeling off of the rashes with skin hypopigmentation and mild pain. After 10 days, he decided to consider herbal medicine and took it for 15 days which was not of any help. The patches kept spreading to his chest, upper limb and legs over the next 15days. The skin peeling continued and was associated with fever in the evenings after coming back home from work. He went to a local doctor and took medicine with saline administered for 3months. The fever subsided on medication with decrease appetite(no significant weight loss) and burning sensation and itchiness over patches and headache over the bitemporal reg
Read more

28 year old women with pain and weakness right upper and lower limb

A 28 year old married woman, farmer by occupation, resident of kunjbihar came to medicine OPD with chief complaints of Pain and weakness in upper and lower limbs since 8 years History of Present Illness - The patient was apparently asymptomatic 8 years ago, then had a sprain with sharp pain in the right hip region while drawing water from well. It was sudden in onset and dragging type of pain. Radiating towards  lower back and slowly spread to right upper limb amd lower limb. Pain aggravated on movement i.e., after work in the nights and relieved on medication, massage and rest. In the last 3 years, weakness has increased and she was not able to perform normal household works. She went to an orthopedicean 3 years ago, pain was relieved on medication, so she discontinued taking medicine, which brought back the pain. Later, she was asked for investigation like blood and x ray. The doctor saw the result and asked her to consult a neurologist, which they didn't consult. She then came
Read more