Gm case 5

A 27 year old female came to opd with a complaints of pain in abdomen .
CASE SCENARIO:
I'm C.Srivally of 3rd BDS .This is an online E log book to discuss our patients de- identified health data shared after taking her guardian's signed informed consent.Here we discuss our individual patients problem through series'of inputs from available global online community of experts with aim to solve those patients clinical problems with collective current best evidence based inputs.
I have been given this case to slove in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, findings, investigations, diagnosis and treatment plan.

CHIEF COMPLAINT:
 Female patient complaints of pain in abdomen nausea and vomitings since 7 days .

HISTORY OF PAST ILLNESS:
Patient was apparently asymptomatic 7 days back then she developed pain in the abdomen that is in the epigastric region which is insidious in onset gradually progressive associated with nausea and vomitings. Pain is burning type with slight radiating  towards left and right which are associated with vomitings 3 to 4 episodes per day which is non projectile, non bilious ,with  food content, the colour of vomiting is white and then changed to yellow colour.

Negative history:
No history of cough, chest pain, palpitations,sweating ,shortness of breath,fever, burning micturition.
No history of hypertension, Diabetes mellitus,asthama,TB, epilepsy, thyroid issues.
Had a caesarean (lscs)9 and 5 yrs back .

PERSONAL HISTORY:
Mixed diet 
Loss of appetite - no
Bowel and bladder - regular
Sleep - adequate
Urine output - normal 
No allergies
No addictions ( tobbacco or alcohol)

FAMILY HISTORY:
not a known case of hypertension diabetes mellitus asthama TB....
But her husband has a history of renal calculus and went on medication and conservation management.

MENSTRUAL HISTORY:
Menarche - 14 yrs of age 
2 days of bleeding every month 

GENERAL EXAMINATION:
Conscious coherent coorperative
Well built and moderately nourished

Pallor - present
Icterus-no
Cyanosis-no
Clubbing - no
Edema-no
Lymphadenopathy-no
VITALS :
Temp - afebrile
Pulse rate - 65bpm
Respiratory rate - 16 cycles / min
Bp - 100/90 mmHg
Spo2-99%in room temp.

SYSTEMIC EXAMINATIONS:

GASTROINTESTINAL TRACT:

Inspection:
Shape is scaphoid
Flancks - free
Umbilicus - inverted
Skin - scars are absent
Dilated veins - no

Palpation:
Inspectory findings are confirmed 
Superficial -
No local rise in temperature
Deep-
Liver - non tenderand non palpable 
Spleen - not palpable and non tender

Percussion:
No fluid thrill ( no shifting dullness)
Liver span - 10cm
No dull sound heard 

Auscultation:
Bowel sounds - 10/ min
Clavicular - supra and infra mammary
Axillary and infra axillary
Suprascapular and infrascapular 
All resonate sound heard 

CARDIOVASCULAR SYSTEM:
INSPECTION:
Bilaterally symmetrical chest present
No scars and sinuses 

PALPATION:
Inspectory finding are confirmed 
Apex beat normal

AUSCULTATION:
S1 S2 heard .Clavicular - supra and infra
Mamillary 
Axillary and infra axillary
Suprascapular and infrascapular 
All resonate sound heard 
RESPIRATORY SYSTEM:

Inspection:
Upper respiratory tract:
Oral hygiene - good
No caries
No halitosis
No nasal septum deviation
No sinus tenderness
Tonsils - no

Lowe respiratory tract:
Chest - symmetrical
No drooping of shoulders
Trachea - midline
No supraclavicular / infraclavicular hollowing
Pectus carinatum- no
Pectus excavaum - no
Kphyphoscoliosis - no


PALPATION:
Inspectory findings are confirmed 
Superficial-
No local rise in temperature
Trachea midline
No drooping of shoulders
Crowding of ribs - no
No dilated veins
Deep -
Chest movements - equal 
Apical impulse - 5 th intercoastal space lateral to mid clavicular line 
Transverse - 50
Anterior posterior - 30
Thoracic circumference - 80
Semi thorax - 40( right and left )

PERCUSSION:
Clavicular - supra and infra
Mamillary 
Axillary and infra axillary
Suprascapular and infrascapular 
All resonate sound heard 

AUSCULTATION:
Normal vesicular breath sounds heard 
12 / min

PROVISIONAL DIAGNOSIS:
Gastritis

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