35F opd vomiting , sob and abdominal discomfort 1 week

 

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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.

C/o vomiting since 1 day 3 to 4 episodes from night 

Sob since 1 day 

abdominal pain since 1 day

Patient was apparently asymptomatic 2 days ago then she developed vomiting since 1 day 3 to 4 episodes from night and containing food particles, non bilious, non projectile non foul smelling, non blood stained associated with nausea 

Sob since 1 day grade 1 aggravating on doing daily household work and releived by taking rest associated with abdominal pain since 1 day At epigastric region which is diffuse type of pain

No h/o fever, cold, cough, allergies 

Ho h/o chest pain, palpitations, and sweating

N/k/c/o htn, dm, epilepsy asthma, cva, cadPersonal history

Occupation homemaker

Appetite: lost, reporter always has a feeling of fullness since 1 week

Bowel and bladder regular

Reporter's daily routine

7:00am wakes up

7-8 preparing breakfast

8-9 eating breakfast 

9-10 washing utensils, washing cloths

10 -12pm rest by watching tv or browsing mobile

12pm-1 preparing lunch

1-2 eating lunch 

2-4 rest by watching tv 

4 -5 preparing tea, cleaning floor

5-7 going for shopping to buy essential, grocery, house hold products

7-8 preparing dinner

8-9 having dinner

9 to 10 preparing for next day breakfast, folding cloths

10pm going to bed

Examination

Pt is c/c/c

No pallor, Cyanosis, clubbing, icterus, pedal oedema

Vitals

Bp 110/80mmhg

Rr 19 cpm

Hr 82 bpm

Spo2 : 99 on room air

ABDOMINAL EXAMINATION:

Inspection:

Shape - distended

Umbilicus - inverted

All quadrants moves equally with respiration 

Scars present 

@ lower mid line incision after lscs

@ port sides for laproscopic cholecystectomy  below xiphi sternum, mid clavicular line below the rib cage, anterior axillary line below tha rib cage, near the umblicus

No engorged veins, visible pulsations,sinuses

Palpation:

All inspectory findings are confirmed 

No local rise of temperature

Abdomen is soft ,tenderness at umbilical and left lumbar region

spleen and liver -not palpable 

No other palpable masses

Hernial orifice are free

Auscultation

Bowel sounds heard

RESPIRATORY EXAMINATION:

Upper respiratory tract - normal

Lower respiratory tract-

Inspection:

Chest bilaterally symmetrical,

Shape- elliptical

Trachea- Central

Palpation:

Trachea is Central

Normal chest movements

Vocal fremitus is normal in all areas 

Percussion: 

in sitting postion

                                      Rt.                      Lt

Supraclavicular. N(resonant).         N

Infraclavicular.              N                   N

Mammary region.        N                    N

Inframammary region. N                   N

Axillary region.            N                       N

Infra axillary region. N                     N

Supra scapular region. N                  N

Interscapular region. N                     N.  

Infrascapular region. N                     N

Auscultation:

Normal vesicular breath sounds

No added sounds

Vocal resonance is normal in all areas

Endoscopy

Electronic summary

Learning points

1.how to take history? 

Start by knowing their  daily routine before the illness and then compare her daily routine during the illness

2.how to differentiate sob is cardiogenic or pulmonary?