A 60 year old female with abdominal pain

This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.

A 60 year old female came to OPD with chief complaints of abdominal pain since 1 month , fever since 15 days and vomiting since 15 days.

HOPI:-   

Patient was apparently asymptomatic 1 month back then she developed abdominal pain in the epigastric and left hypochondriac region, it is sudden in onset , squeezing type pain and is not radiating to back. The pain is more severe after consuming food for about 2 hours and is relieved on taking medication.

It is associated with burning micturation, frothy urine, polyuria and nocturia from past one month.

History of fever since 15 days, which is intermittent, low grade and associated with chills and rigor and relieved on taking medication.

It is associated with vomiting from past 15 days . The vomitus consists of food particles, black in colour, non-bilious, non- foul smelling . She had 4 to 5 episodes of vomiting in past 15 days.

No history of loose stools, chest pain, cough, headache, palpitations, weight loss.

1 year back after covid vaccination , within few hours she experienced numbness of left leg and went to near by hospital and was diagnosed with diabetic foot and had to undergo left below knee amputation. 

From past few months she has a chronic non-healing ulcer on the amputated left foot.

PAST HISTORY:-

History of left below knee amputation 1 year back.

History of hysterectomy 20 years back.

She is a known case diabetes mellitus from past 20 years and also a known case of hypertension from past 1 and half year.

No history of TB, epilepsy, asthma, thyroid abnormalities.

PERSONAL HISTORY:-

Diet- mixed

Appetite- reduced 

Sleep- inadequate 

Bowl and bladder movements- regular

No addictions and no allergies.

FAMILY HISTORY:-  not significant 

TREATMENT HISTORY:-  takes medication for DM and HTN.

Received PRBC transfusion.

GENERAL EXAMINATION:-

- patient is conscious,cooperative and coherent and well oriented to time, place and person.

She is moderately built and moderately nourished.

Vitals:-

●Pulse rate - 87 bpm

●Bp - 130/60 mm/hg

●Temperature - afebrile

●Respiratory rate - 21 cycles per minute 

Pallor - present 

Icterus - absent

Cyanosis - absent

Clubbing - absent

 lymphadenopathy - absent

 Oedema - absent 

SYSTEMATIC EXAMINATION:- 

(1) Per abdomen:-

On inspection :-

Abdomen is scaphoid 

Free flanks 

All quadrants moving equally with respiration 

Umbilicus:-  position- central 

                    Shape - normal 

Skin has stretch marks and hysterectomy scar

No engorged veins

Hernial orifices are normal.

On palpation:- 

No local rise of temperature 

Tenderness over the epigastric and left hypochondriac region 

No hepatomegaly

No spleenomegaly 

Kidneys not enlarged

Presence renal angle tenderness 

No other palpable swellings

Hernial orifices are normal.

On percussion:-

fluid thill/ shifting dullness - absent 

Liver dullness is heard at 5th intercostal space.

On auscultation:-

Decreased bowel sounds heard.

(2) CVS:-

 S1 and S2 heard

No murmurs.

(3) RS:-

Normal vesicular breath sounds.

(4) CNS:-

No focal neurological defects.

PROVISIONAL DIAGNOSIS:-

Acute pancreatitis secondary to cholelithiasis and acid peptic disease .

Hyperkalemia secondary to AKI.

Hyponatremia.

INVESTIGATIONS:-

Ultrasound:-

UGIE report:- 

TREATMENT:-