41year old female with abdominal pain, nausea, vomiting

41 yr old Female with abdominal pain, nausea, vomitings
29 July, 2023

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box are welcome.

CHIEF COMPLAINTS
41 year old female housewife from Miriyalguda came to casualty with C/O:
Nausea and vomiting since 3days
Abdominal pain since 3days

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 4days back then she developed nausea and vomiting, 8-10 episodes of vomiting, content food material watery, non bilious, non projectile, not blood binged and associated with Abdominal pain of diffuse type and non radiating
No H/O chest pain, Pedal edema, burning micturition, coughing, palpitations, excessive sweating, giddiness and wheeze
H/O skipping OHAs since 2 days

HISTORY OF PAST ILLNESS

K/C/O Diabetes Mellitus type 2 since 2 years for which she is on medication (Tab Glimi M1 )
H/o raised blood pressure.
H/o undergoing tubectomy.
No H/o addiction or allergies

DAILY ROUTINE
Patient initially used to wake up at 5:30 am, now she wakes up at around 6 am. She has idli or dosa for breakfast around 7 am. She then does her household chores and has white rice and curry for lunch at around 1:30 pm. She then continues the house hold work or occasionally watches TV till around 7 pm then she starts preparing and has dinner (white rice/roti/howar roti) and goes to bed by around 9 pm.

GENERAL EXAMINATION
Patient is concious, coherent& cooperative
No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema

Vitals
BP: 170/110mmhg
PR: 68bpm
RR: 16 cpm
Temp: 97.8 F
GRBS: 200 mg/dl
SPO2: 98% 

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM EXAMINATION : 
Bilateral air entry +
Normal vesicular breath sounds heard
Trachea - central 
No added sounds 

CVS EXAMINATION : 
S1, S2 heard 
No murmurs 

ABDOMEN EXAMINATION : 
Soft, no tenderness 
No organomegaly
Bowel sounds - present 

CNS EXAMINATION : 
Gcs - E4V5M6 (15/15)
Higher mental functions - normal 
Cranial nerve examination - normal 
Sensory and motor system normal 
No signs of meningeal irritation

INVESTIGATIONS

URINE FOR KETONE BODIES : positive
Chest X-RAY
ECG
2D ECHO
Ultrasound





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