60yr old female came with the complaints of generalised body pains since 10days

  This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered 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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input 

C/o Generalized body pain since 10 days 

C/o abdominal pain since 10 days 

HOPI 

Patient was apparently asymptomatic 20days back and then developed 

fever 20 days back associated with chills rigor palpitations and sob 

H/o vomitings 20 days back food in consistency non projectile 

H/o SOB - grade 3-4 

C/o belching since 2 years 

C/o urine and faecal incontinence since 1 year 


Past : 

H/o acidity since 2 years 

H/o burning micturition took medications 

H/o acute pyelonephritis 

K/c/o DM type 2 since  3 years and on metformin hydrochloride 

N/k/c/o HTN , Epilepsy,tb 

Personal history: 

Diet mixed 

Appetite normal 

Sleep inadequate

Bowel and bladder regular 

No addictions (occassional toddy) 

General examination

Pat is c/c/c well oriented to time place person

She is moderately built and nourished







No signs of pallor , Icterus , cyanosis, clubbing lymphadenopathy,oedema 

Systemic : 

CVS S1 S2 heard no murmurs 

Respiratory BAE present ,NVBS heard 

CNS nfnd


Per abdomen 

Inspection-

Shape of the abdomen:Distended 

Flanks:Free 

Umbilicus:center,oval shape 

Skin-normal ,no sinuses,scars,striae 

No dilated viens 

Abdominal wall moves with respiration 

No hernial orifices 


Palpation:

No local rise of temperature,

 tenderness present in epigastric left hypochondriac region 

All inspectory findings are confirmed by palpation. 

Liver:Not palpable,Non tender,no hepatomegaly

Spleen:Not palpable,non tender,no splenomegaly 

Kidney:Non tender and not palpable 

No other palpable swellings 

Percussion tympanic note 

CVS : S1 S2 heard no murmurs 

Respiratory :BAE present NVBS 

CNS NFND

Investigations: 

RBS -146MG/DL 













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