50 year old female with constipation

December 01, 2021

This is an online E log book to discuss our patient's de-identified health data shared after taking his 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.

PREITY YARLAGADDA

ROLL NO 145

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 diagnosis and treatment plan.

November 30th, 2021.

Case :

A 50 year old female came to the OPD with the chief complaints of

Pain abdomen since 3 days
Constipation since 2 days.

History of present illness :

The patient was apparently asymptomatic 3 days ago when she developed pain abdomen which was insidious in onset and non progressive.
The pain was diffuse, squeezing type and non radiating. There are no aggravating and relieving factors.
The patient has h/o nausea and 4 episodes of vomiting 3 days ago. Vomitings were non projectile, non bilious and the content was food.
The patient also has constipation from 2 days associated with not passing flatus since 1 day.
The patient had chest pain 5 days ago, she was given antacid in the local hospital. The pain relieved upon taking medication.
She has associated SOB of grade 2.

History of past illness :

H/o pain abdomen 2 months ago.
H/o renal calculi 2 years, managed conservatively.
Known case of HTN on irregular medication.
Not k/c/o of DM, asthma and epilepsy.
She was tubectomised 20 years ago.
She underwent hysterectomy 15 years ago.

Personal history :

Mixed diet
Appetite - decreased
Sleep - adequate
Bladder - increased micturition
Bowel - constipation
No addictions.

General examination :

The patient was examined in a well lit room after taking consent.

The patient is conscious, coherent and cooperative. She is well oriented to time, place and person.
She is moderately built and well nourished.
No pallor, icterus, cyanosis, clubbing and lymphadenopathy.

Vitals :

Temperature - Afebrile
Pulse - 77bpm
Respiratory rate - 18cpm
BP - 140/80 mm Hg

Systemic examination :

CNS - NAD
RS - BAE +
CVS - S1, S2 heard

Abdominal examination -

On inspection - Scaphoid abdomen, which is moving with respiration.
On palpation - there is no local rise of temperature. Abdomen is soft. Diffuse tenderness is present but it is more in the Right iliac fossa, hypogastrium and Left iliac fossa. No guarding or rigidity.

Per rectal examinationnation -