General Medicine Case 5

I'm Maimuna Fathima,3rd year BDS July 14,2023

This is an E-log to discuss case scenario of a patient.
I have been given this case to solve in an attempt to understand topic of patient,clinical data analysis to develop my competency in reading and comprehending clinical data including history,clinical findings,investigation and come up with diagnosis and treatment plan.

A 27 year old female,a housewife was brought to OP because of Pain in Abdomen,nausea and vomiting since 4 days.

Chief complaint:
Pain in Abdomen since 4 days 
Nausea and vomiting since 4 days 

History of present illness:
Patient was apparently asymptomatic 4 days ago,then she developed burning type of pain in epigastric,right lumbar and left lumbar region which is insidious in onset,gradually progressive associated with nausea and vomiting.
Pain was aggrevated on food intake and non radiating type. 
She had 3-4 episodes of vomiting per day which was bilious, with no food content,non projectile and associated with Pain in Abdomen. 

History of past illness:
Not a known case of hypertension, Diabetes, TB, epilepsy,thyroid.

Family history:
Not significant 

Personal history:
Diet:Mixed 
Appetite:Decreased 
Bowel and bladder:Regular 
Sleep:Normal 
Allergies:None
Addictions:None 

Drug history:
NaCl inj with Pantop 80mg
Zofer 

General examintion:
Pallor:No 
Icterus:No
Clubbing:No
Edema:No
Lymphadenopathy:No 

Systemic examination:
Inspection:
Shape of Abdomen:Scaphoid 
Skin:Scars,stretch marks present.
No dilated veins 
Umbilicus:central,inverted 
Equal symmetrical movements in all the quadrants with respiration 
No visible pulsation,peristalsis,localized swellings.

Palpation:
Superficial palpation: Tenderness in epigastric,right lumbar and left lumbar regions.
Deep palpation:No spleenomegaly,no enlargement of liver.

Percussion:
Fluid thrill and shifting dullness Absent.

Provisional diagnosis:Acute gastritis.





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