Case of abdominal pain
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Date of admission : 28 November 2021
A 42 year old female who is home maker came to the OPD with the chief complaints of :
Abdominal pain since 3 days
Chest pain since 3 days
Shortness of breath since 1 day
History of present illness :
The patient was apparently asymptomatic 3 years ago
Normal routine of the patient 3 years ago :
The patient used to wake up by 5 AM daily, carried out all the household work, ate some rice at around 10 and then used to go the farm to do some field work. Later she used to return at around 5 and then have some rice at 7/8 PM and sleep by 9/10 PM
3 years back as usually when she used to go to work, she started experiencing abdominal pain and chest pain which was dull in nature.
This worsened and she was brought to our hospital when it was diagnosed as renal calculi. She received 3 day treatment and was discharged.
After discharge, she took herbal medication along with toddy.
2 years back she stopped going to the work and her appetite was lost. She used to have little rice or chapattis whenever she felt like eating.
3 months back, she started experiencing the same abdominal pain and chest pain along with body pains that worsened on 28th November. She experienced shortness of breath that was present while sitting as well.
She had history of vomitings (4 episodes) on the dame day that was non bilious, non blood tinged, non projectile, content was food, and this happened as soon as she ate meals.
She had frequent urination (once in every 2 hours) with pricking type of pain.
She has blurred vision since 6 months and her right eye was injured 3 months back.
She has constipation since 3 days
History of past illness :
The patient is not a known case of diabetes, epilepsy, tuberculosis, asthma, hypertension
She underwent hysterectomy 15 years back
Personal history :
- The patient has loss of appetite
- She takes mixed diet
- No sleep disturbances
- She smokes (chutta) occasionally
Family history :
- There are no similar complaints in the family members
Treatment history :
- She is not a known case of drug allergy.
General examination :
- Patient is conscious, coherent, cooperative at the time of joining
- Pallor present
- No icterus
- No cyanosis
- No clubbing of fingers and toes
- No lymphadenopathy
- Bilateral pedal edema is absent
Pulse rate - 77 bpm
Respiratory rate - 18 cycles per minute
BP - 140/80 mm Hg
GRBS - 136 mg/dl
Systemic examination :
CVS
Inspection - chest wall is bilaterally symmetrical
- No precordial bulge
- No visible pulsations, engorged veins, scars, sinuses
Palpation - JVP is normal
Auscultation - S1 and S2 heard
RESPIRATORY SYSTEM
- Position of trachea is central
- Bilateral air entry is normal
- Normal vesicular breath sounds heard
- No added sounds
PER ABDOMEN
- abdomen is non tender
- bowel and bladder sounds heard
- no palpable mass or free fluid present
CNS
- Patient is conscious
- Speech is present
- Reflexes are normal
Investigations :
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