A 27 year female came to causality with complaints of stomach pain.
This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim to solve the patient’s clinical problem with collective current best evident based input.
This E blog also reflects my patient cantered 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.
This is the case of 27year old female came to causality with complaints of stomach pain
CHIEF COMPLAINTS:
Stomach pain,vomitings
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2 days ago.she then developed stomach pain in the morning
No aggravating and relieving factors
PAST HISTORY:
N/K/C/O Hypertension, Diabetes mellitus,Tb, Thyroid disorders,asthma, epilepsy.
Family History:
No significant family history.
Personal History:
Mixed diet
Normal appetite
Adequate sleep
Regular bowel movements
No history of smoking and chewing of tobacco
GENERAL EXAMINATION:
prior consent was taken and patient was examined in a well lit room.
Patient was conscious, coherent, co-operative
Pallor present
No Icterus
No clubbing
No cyanosis
No generalized lymphadenopathy and bipedal edema
VITALS :
Temperature-98.1F
BP-100/70 mmHg
PR- 65bpm
RR-16 cpm
Spo2-99% at room air
GRBS-174 mg/dl
SYSTEMIC EXAMINATION:
RS: Bilateral symmetrical chest movement and air entry
CVS: S1,S2 heard
No murmurs
PA: soft, no tenderness and distension
CNS : NF NB
Sensory and motor system normal
Investigations:
Acute severe gastritis
