35 year old female with abdominal pain

September 26, 2022

Hello, I am Harika Madala, a 3rd sem medical student.
This is an online e-log book to discuss our patient's health data shared after taking her/his/guardian's consent. This also reflects patient centred care and online learning portfolio.

Chief complaints 


A 35 year old female, housewife, a resident of Miryalaguda presented to the OPD with chief complaints of  

Pain in the upper abdomen since 4 days
Bilateral loin pain since 4 days

History of Present illness 

The patient was apparently asymptomatic 5 days back.Then she developed sudden abdominal pain which was gradually progressive and experienced Bilateral loin pain4 days back for which she consulted an RMP doctor.The pain was not relieved on taking medication. She then presented with fever which is high grade and associated with chills and rigor.

History of Past illness 


No DM
No HTN
No CAD
No Asthma
No TB
No Epilepsy 
k/c/o undifferentiated CTD,probable SLE
Anti CCP +

Personal history 

Married
Appetite- Lost
Mixed diet 
Adequate sleep 
Regular bowel movements 
Burning micturition 

Family history 

Not significant 

Drug history 

Not significant 

Allergies 

No known allergies 

Addictions 

No addictions 

General examination 

The patient is conscious, coherent, cooperative and well oriented 
No pallor 
No icterus 
No cyanosis 
No clubbing of fingers 
No lymphadenopathy 
No pedal edema 


Vital signs 

Temperature: Afrbrile
Pulse rate: 68 beats/min
Respiration rate: 16 cycles/min
Blood Pressure: 110/70 mm Hg
SPO2: 98%

Systemic examination 

CVS
S1 S2 heard
No murmurs
No thrills

Respiratory system 

Dyspnoea- No
Wheezing- No
Central trachea
Vesicular breath sounds 

Investigations

ECG
2D Echo

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