70 year old

 A 70 YEAR OLD FEMALE CAME WITH ABDOMINAL PAIN ASSOCIATED WITH VOMITING.


Hi, I am soumya  3rd 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:

Chief complaints:

A 70 year old female, hailing from valigonda, came with complaints of:
- pain abdomen for 4 days , 15 days back
- skin lesion over chest since 15 days

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 15 days back. She then developed pain abdomen on left side 6 hours after having food. Pain was relieved after taking medication.

 She then went for consultation where show was diagnosed with acute peptic disease and started on medication of clinidium bromide, chlordiazepoxide and dicyclomine, pantaprazol, used for 8 days, on usage of which symptoms relieved. 

She was then found to have decreased hemoglobin levels for which she was admitted for further management.

Past history:

-15 years back, she was diagnosed with hypertension and was on medication with tab: atenelol 50mg.

- 2 years back , patient has history with white and bloody discharge per vagina for which she was diagnosed as carcinoma endometrium stage I and underwent concurrent chemo-radiotherapy.

-History of similar complaints 5 years back.

- 4 years ago, she has a history of fall from auto, for which she was treated with proximal femur nail.

Personal history:

Diet: Mixed
Bowel : regular
Micturition: normal
Appetite: Decreased
Habits: nil
No history of allergy, asthma, tuberculosis, coronary artery disease.

Family history:
Insignificant

GENERAL EXAMINATION:

pallor present
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration
No pedal edema

VITALS:

Temperature: 98.4 F

Pulse: 64 beats per minute

Respiratory rate: 20 cycles per minute

Blood pressure: 140/80 mm of Hg

SPO2: 99%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
murmurs: systolic murmur
Cardiac sounds: S1, S2 heard

Respiratory system:

No dyspnea 
No wheezing
Breath sounds heard: vesicular

Abdomen:

No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard

Central Nervous System:

Conscious
Speech: normal

Investigations:
USG:
ECG:
Provisional Diagnosis:
Iron deficiency anemia secondary to endometrial carcinoma.

Complete blood picture:

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