50 year old female with 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.
50 year old female daily labourer by occupation came with
Chief complaints:
Abdominal pain since 5months
Itchy lesions on abdomen since 1 year
History of presenting Illness :
Patient was apparently asymptomatic 5 months ago then she developed abdominal pain insidious in onset non progressive in epigastric region and right hypochondrium ,later progressive to diffuse abdominal pain .pain is more after intake of food ( non radiating type ).
No H/O vomiting,loose stools ,hematemesis,fever ,cough ,Shortness of Breath, palpitations.
Pedal edema present (occassionally)
Itchy lesion on abdomen since 1 year (took treatment).
Past history :
No H/O similar complaints in the past
Not a K/C/O DM ,HTN ,TB ,ASTHMA , THYROID, EPILEPSY.
Personal History:
Daily labourer by occupation
Diet mixed
Appetite normal
Adequate sleep
Bowel and bladder movements are regular
Addictions - occasional toddy drinker.
Menstrual history:
Menarche - 12 years
Duration -4/30
Uses 3 pads per day
No clots
LMP -10/4/2023.
Obstetric History:
2 children ( Normal vaginal delivery)
Family history:
No significant family history
Treatment History:
Treatment taken for itchy lesions on abdomen (name bot specified).
General Examination:
Patient is conscious, coherent, co-operative
Well nourished,well built .
No signs of pallor , icterus, cyanosis, clubbing, lymphadenopathy.
Pedal edema present occassionally.
Itchy lesions prensent over abdomen
Vitals :
Blood pressure -140/90 mm Hg
Pulse rate - 78 bpm
Respiratory Rate - 16 cpm
Temperature -96.8 ° F
Systemic Examination :
Per abdomen:-
Inspection -
Shape of abdomen : scaphoid
Umbilicus : inverted
Movements of abdomen wall with respiration
Itchy lesions present over abdomen
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
On palpation -
No local rise of temperature
Inspectors findings are confirmed
Soft and non tender
No palpable mass
Liver and spleen not palpable
On percussion -
Resonance note heard
On auscultation -
Bowel sounds heard
Respiratory System:-
Inspection
Trachea appears to be normal - Central
shape of chest - elliptical
Movements of chest appear to be bilaterally equal
No scars , sinuses present.
No drooping of shoulder
No engorged veins , swellings seen
No hallowing seen
No crowding of ribs
Palpation:
All inspectory findings are confirmed
No rise of temperature
No tenderness
Trachea is in midline
B/L chest movements are equal
No swelling and palpable masses are felt
vocal fremitus are normal
Percussion
Resonance heard over all regions.
Auscultation
Normal vesicular breath sounds heard .
CVS Examination
No raised JVP
Bilaterally symmetrical expansion seen
No dilated veins ,engorged veins ,scars .
Apex beat felt at 5th ICS
S1 S2 heard.No added murmurs or thrills heard.
INVESTIGATIONS:
Diagnosis -
Abdominal pain under evaluation
Grade 1 fatty liver
Tinea cruris
Treatment :
Pan 40 mg PO/OD - 1/2 BBF
Lulfin cream (morning and night) - 2 weeks
Cap. Alcros BD (Itraconazole) -2 weeks
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