32 year old female with vomitings and abdominal pain.

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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 32 year old female farmer by occupation came to general medicine OPD with chief complaints of vomitings (4 to 5 episodes/ day) since 2 days associated with abdominal pain.

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic few days ago.On 22/12/2022 around 10 pm she had 2 episodes of vomiting after 4 hours of food intake. On 23/12/2022 in the morning hours, another 2 episodes of vomiting after intake of milk and coconut water ,few more episodes of vomiting till she came to the hospital. Vomiting was non projectile, non bilious,non foul smelling and has food as contents associated with abdominal pain(epigastric region). Pain aggrevated after intake of food.

No history of diarrhea, burning micturition, headache , giddiness .

No H/O fever.

PAST HISTORY 

In the last week of November (25/11/22) she developed fever and pain in lower abdomen . The pain was insidious and gradual in onset and lasted for more than 2 weeks. On consultation with a gynaecologist, undergoing certain investigations she was diagnosed with ovarian cyst and had a surgery on 7/12/2022. 

Surgical history of right salpingo oophorectomy on 7/12/2022 for ovarian cyst has been performed. 1 unit of blood transfusion was done.

She was discharged after a week on 15/12/22.

Patient is not a k/c/o Diabetes Mellitus, Hypertension,Asthma, Thyroid disorders, Epilepsy, Tuberculosis.

FAMILY HISTORY 

Not significant.

PERSONAL HISTORY 

Mixed diet

Normal appetite 

Adequate sleep

Bowel and bladder movements are normal

Addictions - occasional toddy drinker

No allergies 

MENSTRUAL HISTORY 

Age of Menarche :15 years

Menstrual cycle 4/30, regular 

LMP: 22/11/2022

GENERAL EXAMINATION

Patient is Conscious, coherent and cooperative

Pallor present

No signs of icterus, clubbing, cyanosis, lymphadenopathy, generalised edema.

Vitals:

Temperature :afebrile 

Pulse Rate: 80 beats per minute 

Respiratory rate: 18 times per minute 

BP: 120/70 mm of Hg

SpO2 : 87% at room temperature

GRBS- 95 mg / dl

SYSTEMIC EXAMINATION 

Abdominal examination:

Inspection 

Umbilicus inverted , No abdominal distention,no visible pulsations,scars and swelling.

Palpation 

Soft, non tender, no organo megaly.

Auscultation

Bowel sounds heard.

Cardio vascular examination:

No visible pulsations, scars, engorged veins. No rise in jvp 

Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.

 S1 S2 heard . No murmurs.

Respiratory system :

Shape of chest is elliptical, b/l symmetrical.

Trachea is central. Expansion of chest is symmetrical

 Bilateral Airway Entry - positive

 Normal vesicular breath sounds

CNS examination: No neurological deficit found.

Gait: normal.

Normal speech.

Reflexes are normal

PROVISIONAL DIAGNOSIS:

Acute Enteritis 

INVESTIGATIONS 

ECG 

Ultrasound 

Treatment :

1.IVF NS @ 50ml/hr

2.Inj.ZOFER 4mg/IV/SOS

3.Inj. PAN 40mg/IV/OD