Hi, I am Yeddula Vishnu Priya, 3rd semester medical student. This is our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. This elog also reflects my patient centered online learning portfolio
33 year old female resident of west bengal came to opd with lower abdominal pain
CHIEF COMPLAINTS
She came with a chief complaint of pain radiating from groin to right flank region gradually increasing since 3 years.
C/O nausea and vomiting since 3months
C/O no fever
HISTORY OF PRESENT ILLNESS
Patient is apparently asymptomatic 3 years ago.
Then she developed pain in the right groin region which radiated to right flank region
It was gradually increasing pain.
Aggrevating factors : on walking, or doing heavy work
Has dull pain during rest.
It severely increased 3 months ago.
She also complaints of nausea and vomiting since 3 months which relieved on medication.
She complaints of burning micturition since 5 days.
C/O dysuria
No white discharge
HISTORY OF PAST ILLNESS
No HTN/diabetes
She had undergone tubectomy 5 years ago.
PERSONAL HISTORY
Patient is a home maker by occupation
married with 3 kids
Bowel movement is regular
Burning Micturition
Non alcoholic
FAMILY HISTORY
No significant family history
PHYSICAL EXAMINATION
A. GENERAL EXAMINATION
Well built
Well nourished
No pallor
No icterus
No cyanosis
No pedal oedema
No clubbing of fingers
No lymphadenopathy
Mild dehydration
B. VITALS
Temperature - Febrile
Pulse - 92 bpm
Respiratory rate - 17
BP - 110/80
GRBS - 88 mg%
SYSTEMIC EXAMINATION
A. CVS
- No thrills
- S1 S2 positive
-no cardiac murmurs
B. RESPIRATORY SYSTEM
- no dyspnoea
- No wheezing
- central trachea
- vehicular breath sounds
C. ABDOMEN
- scaphoid shaped abdomen
- No tenderness
- No palpable mass
- non palpable liver and spleen
C. CNS
- conscious and coherent
- normal speech
INVESTIGATIONS
1. ECG
2. USG
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