40 year old female


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



A 40 year old female patient resident of Nalgonda, came to the General Medicine OPD with-

CHIEF COMPLAINTS:

C/o giddiness since 2 days
C/o generalized weakness since 2 days
C/o chest tightness and abdominal discomfort since 1 day
HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 2 days back and then she started feeling weak and was not able to perform her daily tasks as she used to do before, and C/o:

1 day back, she felt giddy and weak in the morning which was relieved on taking medication.

She had another similar episode in the evening which did not relieve with the same medication. She went to a local RMP who found her to be hypotensive and started her on I.V Fluids.

Approximately 6 hours later the patient developed generalized weakness and went to a government hospital. Her BP there was found to be 190/120 mmHg and she was treated with T. VERTIN and T. AMLODIPINE.

She persistently felt weak and was anxious about her health and so was brought to KIMS. When checked for vitals she had low BP and was admitted on 19/4/23.

She also c/o abdominal discomfort since 1 day. She has a feeling of abdominal distension along with burning sensation in chest and chest tightness which is relieved on eating.

The 2 episodes of giddiness were associated with diffuse intermittent headache, nausea and tremors.  No positional variation. No c/o vomiting, postural hypotension, aggravation with head movements or any hearing disturbance 

No c/o any fever, loose stools, vomiting, burning micturition, cough or cold

No c/o palpitations or SOB

HISTORY OF PAST ILLNESS:

Patient has been having the symptoms of abdominal discomfort with burning sensation on and off since 1 year

Recently, she had similar complaints 1 month back, which were relieved on medication. 

(Syr. MUCAINEGEL 10 ml TID; Tab. PAN 40 mg PO/OD/BBF; Tab. CLONAFIT BETA)

Used antihypertensive medication 1 month back for 5 days and then stopped.

Not a k/c/o Diabetes Mellitus, asthma, TB, epilepsy, CVA,CAD, thyroid dysfunction

1 lower segment C section done 21 years back due to abnormal presentation of baby after which she also had tubectomy done.

No h/o any blood transfusions. 

PERSONAL HISTORY:

Takes mixed diet, 

Normal appetite

Bowel and bladder are regular

Sleep adequate

Occasionally drinks toddy or beer (once in a month)

No known allergies

FAMILY HISTORY:

No significant family history

MENSTRUAL HISTORY:

Age of Menarche- 13 yrs
Menstrual cycle- 3/28
Normal flow, Regular cycles, No clots 
LMP- 11/4/23

PHYSICAL HISTORY:

GENERAL EXAMINATION:

Pt is c/c/c
Pallor- absent
Icterus- absent
Cyanosis- absent
Clubbing- absent
Lymphadenopathy- absent 
Pedal oedema- absent
Malnutrition- absent
Dehydration- absent

VITALS:
Temp- Afebrile on touch
PR- 76 bpm 
RR- 16 cpm
BP- 110/80 mmHg
SYSTEMIC EXAMINATION:

ABDOMEN:

1) Inspection: 
Shape- Obese

Flanks- Free 
Umbilicus- central and inverted
Skin- presence of c-section scar and striae
No engorged veins
Movements of the abdominal wall- uniform on respiration
Hernial orifices, cough impulse- normal
2) Palpation:
     
    a) Superficial Palpation:
No tenderness
Warmth- no local rise in temperature
    b) Deep Palpation:
Liver
Spleen
3) Percussion:
No fluid thrill
No shifting dullness
Percussion of liver span
Percussion of spleen
4) Auscultation:
Bowel sounds-
Bruits- No Renal artery bruit ; No Aortic artery bruits ; No Hepatic artery bruits


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