A 29years old female with pain in right hypochondrium.
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
10/3/22
A 29year old female came to the opd with chief complaints of pain in the right hypochondriac region since 6 months.
History of presenting illness:
She was apparently asymptomatic 6months back then she developed pain in the right hypochondrium which was sudden in onset with high intensity and it is radiating to back(at back it becomes stagnant) aggravated on taking spicy and heavy food and relieved temporarily on taking medication.
She also has the h/o of Abdominal discomfort by eating spicy and heavy food,it relieves after inducing vomiting by herself.
She has a h/o weakness associated with dizziness during her 2nd pregnancy in 3rd trimester.
She has a h/o high grade fever with chills and rigor and associated with dizziness after 20days of her post partum period of second pregnancy. After that she has only h/o of low grade fever.
Past history :
No h/o Hypertension,diabetes,epilepsy,tuberculosis,asthma
Not significant
Menstural history:
Age of menarche-12yrs
Menstural cycle-altered(1cycle/2-3months)
Duration of bleeding-6days
Decreased flow of bleeding
Changes 2 clothe pads/day
Obstetrics history:
Parity-2.
Trimesters-not significant.
Full Term-Normal vaginal delivery.
Personal history:
Diet-mixed
Sleep-adequate
Appetite-normal
Bladder-regular
Bowel-irregular
Addictions-none
General examination:
Patient was conscious,coherent,cooperative and well oriented to time place and person.
Moderately built and nourished
Pallor-present
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Edema-absent
Vitals:
Temperature-98.5F
Pulse-99bpm
Respiratory rate-18cpm
Blood pressure-110/90mmHg
Spo2-99%
GRBS-115mg%
Systematic examination:
CVS-S1S2,no murmurs
RS-BAE+
P/A-soft and non tender
CNS-NAD
Investigations:
Hemogram:
Hb-10.9
TLC-5,900
Pl-2.77
LFT:
TB-0.77
DB-0.16
AST-21
ALT-19
ALP-269
TP-6.8
ALB-4.8
RFT:
Urea:-20
Creatinine:-0.7
Ca++-:9.6
Po4-:3.9
Na+:156
K+:4.0
Cl-:98
CUE:
ALB-Trace increased
Sugar-Nil
Pus cells:-2-4
Epithelial cells:-2-3
ECG:
There is history of high grade fever with chills and rigor 20 days after the delivery of her second child. That was the only episode of high grade fever nevertheless she complains of several other times when she had low grade fever.
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