56 yrs old female came to OPD with epigastric pain since 1 week.



8th June, 2021.                



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56 yrs old female came to OPD with epigastric pain since 1 week.

Lakshmi Manvitha Yechuri
Roll no:169 

A case discussion of Epigastric pain since 1 week.

I've 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 a diagnosis and treatment plan.      

Following is the view of my case :

Case admitted under unit 2

History was taken by 

Dr.A. Vaishnavi Mam PG y2

Dr. M. Vinay Sir  PG y1

and helped by the interns

  •     G.Sai Vittal Sir
  •     Ch.Rishik Sir
  •     G.Preethi Mam
  •     Deekshitha Mam 


CASE PRESENTATION

Chief complaints

Epigastric pain burning type since 5yr(on and off) Regurgitation symptoms since 1 week


HISTORY OF PRESENT ILLNESS 


Patient was apparently asymptomatic 5 years back later on she developed.
                                     
1) epigastric pain burning type , Aggravating on supine position and relieving on medication.      

Since then she is having similar episodes which was relieving on medication. 

Since one week she came with chief complaints of epigastric burning type of pain Aggravating on supine position 

2) she also came with reflux symptoms such as burning sensation in throat , acid reflux 


 Negative history : no history of fever, cold , cough, no history of abdominal distinction/ pedal edema     
No history of burning micturition    

PAST HISTORY  

 5 years back she had chief complaints of pain in right hypochondrium diagnosed with cholelithiasis.

No history of Hypertension, Diabetes mellitus, Epilepsy, Tuberculosis, Coronary artery disease , CUA.


PERSONAL HISTORY:

Diet         : Vegetarian 

Appetite :  Normal 

Sleep      : Adequate 

Bowel and bladder : Regular 

Micturition : Normal 

No addictions


FAMILY HISTORY:

Not significant.


GENERAL EXAMINATION: 

Patient is conscious, coherent and cooperative.

She is well oriented to time, place and person. 

She is  moderately nourished.

No Pallor

No Icterus

No Cyanosis

No Clubbing

No Lymphadenopathy

No Edema


VITALS: 

Temperature: 98.2F 

Pulse rate -92 bpm

Respiratory rate - 18 cpm 

Bp: 110/80mmHg

SPO2 : 98%


SYSTEMIC EXAMINATION:

Cardiovascular system : S1, S2 is heard. No murmurs are heard.

Respiratory system : Bilateral air entry is present, Normal vesicular breath sounds are heard. No adventitious sounds are heard.

Per Abdomen : Soft, Non-tender

CNS EXAMINATION: intact 


DENTAL CONSULTATION: 

Chief complains: of ulceration on tongue and palate mucosa 

On examination: no frank ulceration 

Treatment tab Zincovit


RADIOLOGICAL CONSULTATION 

Brief Clinical details - Pain in the left hip region since 7 years known case spondyloarthropathy.

? SLE 

Multiple join involvement present 


Provisional diagnosis : ? SLE 


Investigations: MRI for both hips bilateral 


Region of interest/Special procedures : bilateral hips


ORTHOPAEDIC CONSULTATION 

50 year old female having history of spondyloarthropathy since 7 years

Chief complaints of :

Pain at left hip since 7 years

History of cervical pain, left Knee joint pain

No history of fever

On Examination:

Patient is conscious, coherent, cooperative 

GC - fair

CVS - S1and S2 sounds heard

CN - NAD

P/A - soft and non tender

RS - BAE+

On local Examination of left Hip:

No swelling

Tenderness at terminal flexion

ROM- Terminal flexion painful 

Abduction upto 150 degrees

Flexion is limited

Treatment:

Review Reports 





ENT CONSULTATION :

On examination of Oropharynx :- 

PPW- Granular congested 

Anterior pillar - Normal 

Posterior pillar - Normal

Uvular/ soft palate - Normal 

Posterior 1/3rd of tongue - Normal 

No Palpable Lymphnodes


Provisional diagnosis :- 

 Acute pharyngitis with GERD 

 

Treatment :- 

1. Injection Pantop.

2. Life style modifications

3. Warm water gargles 3 to 4 times / day


SURGICAL CONSULTATION:

Patient was presented to OPD at 3:40pm patient came with 

Chief complaints of

1) Pain in right hypochondrium since 2 months chief complaint of belching since 2 months complain of nausea on and off 

No history of vomiting  patient was apparently asymptomatic 2 months ago then she developed pain in right hypochondrium which was sudden in onset, gradually progressive, colicky type pain radiating to right scapula and intrascapular region with no Aggravating and relieving factors 

Compliant of belching no history of vomitings, loose stools , constipation history of similar complaints in the past Gallbladder stones - 3mm, 5 years back

 No history of any Any Surgeries. Not a known case of diabetes Mellitus, hypertension, CAD , CKD, thyroid disorder 

On examination : conscious, coherent, cooperative 

Temperature : afebrile. 

Bp-130/80 mmhg 

PR- 80bpm

Heart sounds -S1 S2 sounds heard 

Respiratory- BAE positive clear 

Per abdomen - soft, non tender, No guarding,rigidity

Impression - Asymptomatic cholelithiasis 

Plan : Open/ LAP cholecystectomy

Treatment: 

CST as per physician order

Tab DOLO 650 mg/PO/SOS


GYNAECOLOGY CONSULTATION 

56 old P2L2A5 Post menopausal came with incidental findings from outside scan report showing left ovarian simple cyst measuring 1.5 x 1.3cm 

No history of pain abdomen , white discharge 

Complaint of Burning micturition (on and off) since 1 year 

No history of Dysuria, nocturia


Known case of Gastritis and on antacids since 5-6 years 

No history of post coital bleeding 

Past history

No history of major surgeries in the past 

No history of fever,  cold , cough, vomiting , loose stools, constipation 

Not a known case of hypertension,  diabetes mellitus, TB, Epilepsy,  bronchial asthma , CAD,CUD, Thyroid disorders 

Family history of Gall bladder carcinoma to mother 

Reached menopause 6 years back 

Previous menstrual history 

AOM - 13 years 

8/30 , Regular

No pain 


Marital history 

Married life - 40 yrs

Non Consanguine marriage


OBS history 

P1L1- male,  35 years , FTNVD( full term normal vaginal delivery)

A1- spontaneous at 1and a half month 

P2L2- female, 30yrs FTNVD( full term normal vaginal delivery)

A2A3A4- Spontaneous at second month

Non Tubectomised


On Examination :- 

Gc - fair 

Temp- Afebrile 

Bp - 130/80mmHg 

Pulse rate - 73 bpm


Systemic examination 

H/l - S1 and S2,

Respiratory system - BAE + 

Per abdomen - soft ,  non tender 


P/S - cervix   : Healthy 

         Vagina  : Healthy, no  diseases 

P/U - Uterus  : Anteverted  , normal size, mobile, non tender

B/L fornices free, non tender

56 yr old P2 L2 A5 post menopausal non- tubectomised with simple ovarian cyst left side

Advice :-  

As the cyst size is 1.6 x 1.3 cm which is a functional type ( functional cyst) 

< 6cm of cyst size.  No active gynecological intervention required. Only observation  is required with following scans for every 3 months to look for the size of cyst.


PAP taken - 2477

USG abdomen and pelvis

Uterus - post menopausal status 

Right and left ovaries - not visualised 


Gastro Enterology Consultation.       

Esophagus: Lax LES, Hills grade 1 

Stomach : Atrophic Fundus mucosa seen , erythema in antrum 

Duodenum : cap normal, D2 normal

Impression

     LaxLES 

     Atrophic fundal gastritis 

     Erythematous antral gastritis







INVESTIGATION: 

Complete blood picture 


Complete urine examination


LFT 



RFT 


Hemogram



Serum iron


Ferritin


Random Blood sugar 



Ultrasonography 







 PROVISIONAL DIAGNOSIS

GERD( Gastroesophageal reflux disease) 


TREATMENT

Tab Pantop 40 mg/PO/OD








I would like to thank Dr.Rakesh Biswas sir(H.O.D,General Medicine) for giving me this opportunity and Dr.A.Vaishnavi Mam(P.G, y2)and 
Dr. M. Vinay PG y1
and also
G.Sai Vittal Sir 
Ch.Rishik Sir 
Deekshitha Mam
G. Preethi Mam for their guidance and support.

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