A 70 YEAR OLD FEMALE CAME WITH ABDOMINAL PAIN ASSOCIATED WITH VOMITING
15 November, 2022
E LOG GENERAL MEDICINE
Hi, I am G.Akshara , 3rd Sem Medical Student. This is an online e-log book to discuss my patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
* This is an ongoing case. I am in the process of updating and editing this ELOG.
CASE SHEET:
Chief complaints:
A 70 year old female, hailing from valigonda, came with complaints of:
- pain abdomen for 4 days , 15 days back
- skin lesion over chest since 15 days
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 15 days back. She then developed pain abdomen on left side 6 hours after having food. Pain was relieved after taking medication.
She then went for consultation where show was diagnosed with acute peptic disease and started on medication of clinidium bromide, chlordiazepoxide and dicyclomine, pantaprazol, used for 8 days, on usage of which symptoms relieved.
She was then found to have decreased hemoglobin levels for which she was admitted for further management.
Past history:
-15 years back, she was diagnosed with hypertension and was on medication with tab: atenelol 50mg.
- 2 years back , patient has history with white and bloody discharge per vagina for which she was diagnosed as carcinoma endometrium stage I and underwent concurrent chemo-radiotherapy.
-History of similar complaints 5 years back.
- 4 years ago, she has a history of fall from auto, for which she was treated with proximal femur nail.
Personal history:
Diet: Mixed
Bowel : regular
Micturition: normal
Appetite: Decreased
Habits: nil
No history of allergy, asthma, tuberculosis, coronary artery disease.
Family history:
Insignificant
GENERAL EXAMINATION:
pallor present
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration
No pedal edema
VITALS:
Temperature: 98.4 F
Pulse: 64 beats per minute
Respiratory rate: 20 cycles per minute
Blood pressure: 140/80 mm of Hg
SPO2: 99%
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
murmurs: systolic murmur
Cardiac sounds: S1, S2 heard
Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular
Abdomen:
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious
Speech: normal
Investigations:
Complete blood picture:
USG:
ECG:
Provisional Diagnosis:
Iron deficiency anemia secondary to endometrial carcinoma.
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