General medicine case discussion
April 20,Case scenario.......
Hi, I am M.Yamini , 5th sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.
CASE SHEET:
The 36 year old female, occupation by farmer ,came from thirumalagiri to general medicine opd.
Chief complaints:
Pain in abdomen since 1 month , vomiting once in 10 days .
HISTORY OF PRESENT ILLNESS:
Patient Was apparently Asymptomatic 1 month back ,but suddenly she was developed pain in abdomen & vomiting once in 10 days
Region: epigastric region
Type of pain: non radiating type & crushing type of pain
She developed pain in abdomen once in 10 days relieved by vomiting,she developes vomiting mostly in the early morning
Contents :food particles
Non projectile type of vomiting
Bilious type of vomiting
She didn't take any medication for her pain in abdomen & vomiting,but she takes ors /eno after vomiting
Yesterday ,she developed hematemisis
Colour:Dark Red
Then she came to our opd today
Not associated with fever , headache, chest pain
PAST HISTORY:
The patient had no significant history suggestive of DM, hypertension,CVD,
No similar complaints in the past
16 years back patient developed renal stones,then she consult doctor,she was on medication on past then stones are dissolved
PERSONAL HISTORY:
Appetite: Normal
Diet: mixed
Bowel movement present
Sleep:adequate
No addiction s
FAMILY HISTORY: insignificant
Drug history:No drug history
Menstrual history:
Meanarche :at the age of 13 years
3 children s (boy ,girl,boy) 3 Cesarian Section s
Menstrual cycle:30/5
PERSONAL HISTORY:
Appetite: Normal
Diet: mixed
Bowel movement present
Sleep:adequate
No addiction s
FAMILY HISTORY: insignificant
Drug history:No
Food allergy: brinjal, chicken.
GENERAL EXAMINATION:
Patient is conscious, coherent,cooperative,i and moderately built & moderately nourished
Icterus: absent
Pallor: absent
Clubbing: abesnt
Edema: present
No generalized lymphadenopathy
