60years female with pain abdomen

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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.

Chief Complaints:

Pain abdomen since 2months

History Of Presenting Illness:

Patient  was apparently asymptomatic 2months back then she developed pain in hypogastric region which was inscidious in onset,continuous,pricking type,non radiating,no aggravating factors and relieved temporarily on taking pain killers.

C/o bilateral foot and hand tingling sensation since 1year.

C/o burning micturation 

No c/o cough,sob,palpitations,

sweating 

No c/o vomiting,nausea,loose stools

No c/o polyuria,polydipsia,polyphasic,fatigue

k/c/o DM since 15days

Daily routine:

Wakes up at 6am,does her house work and takes bath and takes breakfast by 8am and takes insulin injection at 10:50am and then takes her her lunch around 11am and then sleeps or watch tv and have tea and biscuits in the evening and then takes insulin injection at 8pm and then takes dinner, does some household work and sleeps by 10pm.

Past History:

H/o 2 classic LSCS 

H/o hernia surgery 10years back.

N/k/c/o HTN,Epilepsy,Tuberculosis,CAD,CVA

Personal History:

Diet : Mixed 

Appetite : Normal

Sleep : Normal

Bowel and bladder moments :Regular 

Addictions:none

Family History:

Not significant 

General physical examination:

Patient is conscious ,coherent,cooperative and well oriented to time, place and person.

Well built and nourished.

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema:absent 

Vitals:

Temperature - 98*F

PR :- 83beats per minute 

BP :- 120/70mm Hg

RR:-18 cycles per minute

SpO2-98%

GRBS-362mg/dl

Systemic examination:

Per Abdomen:

Shape of abdomen-distended

Umbilicus -inverted

Abdomen moves accordingly with respiration.

 No sinuses

Horizontal Scar present in umbilicus region(above umbilicus)

Vertical scar present below umbilicus

Abdomen is soft,non tender.

No free fluid

Hernial orifices-Normal

No organomegaly

Bowel sounds- present 

Cardiovascular system: 

Inspection-

Shape of chest-Normal  

No precordial bulge.

No dialated veins,scars and discharging sinuses.

No visible pulsations.

Palpation-

 Apical beat felt in 5th intercostal space.

No parasternal heave and thrills

Auscultation-

S1S2 heard 

No murmurs heard

Respiratory system:

-Inspection:

Trachea -appears to be central

Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.

elliptical in shape.

No chest wall defects.

No scars and sinuses.

-Palpation:

All the inspectory findings are confirmed.

Trachea central in position

Measurements 

AP diameter-16cms

Transverse -26cms 

Tactile vocal

Fremitus                   Right              Left

Supraclavicular          N                  N

Infraclavicular           N                   N

Mammary                   N                   N

Inframammary          N                   N

Axillary                        N                   N

Infraaxillary               N                    N

Suprascapular           N                    N

Infrascapular            N                     N

-Percussion                Right              Left

Supraclavicular          R                   R

Infraclavicular           R                    R

Mammary                   R                    R

Inframammary          R                    R

Axillary                        R                    R

Infraaxillary               R                    R

Suprascapular           R                    R

Infrascapular             R                   R

R-Resonant

-Auscultation        Right              Left 

Supraclavicular     NVBS             NVBS

Infraclavicular       NVBS             NVBS

Mammary               NVBS             NVBS

Inframammary      NVBS              NVBS  

Axillary                    NVBS              NVBS

Infraaxillary            NVBS              NVBS

Suprascapular        NVBS              NVBS

Infrascapular         NVBS              NVBS

(NVBS- Normal vesicular breath sounds)

Central Nervous system:

Conscious

Cranial nervers -normal

Tone                 Rt                  Lf 

UL                     N                   N

LL                      N                   N

Power               Rt                  Lf

UL                    5/5                 5/5

LL                     5/5                 5/5

Fine touch       Rt                  Lf 

UL                     N                   N

LL                      N                   N

Reflexes.          Rt.                 Lt

Biceps               ++                 ++

Triceps             ++                  ++

Supinator        ++                  ++

Knee                 ++                  ++

Ankle                +                     +

Investigations:

Liver Finction test:

Total bilirubin-1.14mg/dl

Direct bilirubin-0.35mg/dl

SGOT-22 IU/L

SGPT-21IU/L

Alkaline phosphate-354

Total proteins-7.2g/dl

Hemogram:

Hemoglobin-12gm/dl

Total count-13800cells/m3

Platelets:4.24L

Renal function test:

Urea-28mg/dl

Creatinine-0.8mg/dl

Uric acid -4.8mg/dl

Chloride-105

Sodium-143

Potassium-3.8

CUE:

Albumin-Trace

Pus cells-50 -60

Rbc- 1-2

Epithelial cells-2-4

Sugars- ++++

Rbs-243mg/dl

HbA1c-7.5

Provisional Diagnosis:

Urinary Tract infections 

Dyspepsia

K/c/o Diabetes since 15years

Treatment:

STRICT DIABETIC DIET 

INJ BIPHASIC ISOPHANE INSULIN 30/70 SC/BD PREMEAL

Tab NITROFURANTOIN 100mg PO/BD

TAB PAN 40MG PO/OD BBF

TAB PREGABLIN 75MG PO/HS 

MONITOR VITALS 2HHOURLY

GRBS 7 POINT PROFILE