Case 3

27 YEAR OLD FEMALE WITH COMPLAINTS OF PAIN IN ABDOMEN

July 19, 2023

A 27 year old female homemaker resident of Chouttupal came with chief complaints of pain in abdomen, nausea and vomiting

History of present illness: 

Patient was apparently asymptomatic 4 days back when she developed pain in epigastric region which is insidious in onset, gradually progressive associated with nausea and vomiting. Pain is burning type with slight radiation towards both flanks(Left >> Right). She had history of eating spicy chicken curry and 2 tandoori roti just the night before the pain started, next day morning during drinking tea the pain started. She also has a h/o food intake at irregular intervals.

H/o Vomiting since 4 days (3-4 episodes/day), non projectile, non bilious, food as content (initially clear-whitish in color subsequently changed to green-yellowish).

No history of cough, chest pain, palpitations, sweating and shortness of breath.

No history of burning micturition, hematuria and fever.

Past history :

No history of Hypertension, Diabetes Mellitus, Bronchial asthma,TB , Epilepsy, thyroid disorders.

H/o 2 previous LSCS 9 and 5 years back.

Personal history: 

Her appetite is normal

She takes a mixed diet

Her bowel and bladder movements are regular

Sleep is adequate 

Urine output is normal 

No known allergies 

No known addictions

Family history: 

Her husband is diagnosed with renal stones for which he is on medication and conservative management.

Menstrual history:

Menarche at 14 years of age.

Menstrual cycle 30 days cycle with 2 days of bleeding.

LMP: 10/07/2023

General examination: 

Patient is conscious, coherent and coperative well built and well nourished.

Vitals:

Temperature: Afebrile

Pulse rate: 65 bpm

Respiratory rate: 16 cpm

Bp: 100/70 mmhg

Spo2: 99%in room air

G/E:

Pallor : Present

No icterus

No cyanosis

No clubbing

No koilonchya

No lymphadenopathies

No Pedal edema

RT renal calculus

Multiple tiny hyperechoic foci noted in the hall bladder 

Systematic Examination:

-CVS:

S1 and S2 are heard

No thrills and no murmurs were heard

-Respiratory: 

Vesicular breath sounds heard

Trachea is in central position

No wheezing

No Dyspnoea

-Abdomen:

Scaphoid shaped abdomen 

No tenderness

No palpable mass

No hernial orifices

No free fluid

Liver and spleen are not palpable

Bowel sounds are heard

-CNS:

Conscious and normal speech

Normal gait

Crainial nerves are normal

Sensory system is normal

Motor system is normal

Investigations:

Serum creatinine: 0.8

Blood urea: 14mg/dl

RBS : 84mg/dl

Albumin: 3.71

Serum Na+ :145 mEq/L

Serum K+ : 4.0 mEq/L

Serum Cl- :102 mEq/L