Geetha. 54

38years with Cholelithiasis

10 April 2022

This is an online E log book to discuss our patient's 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 global online community of experts with an aim to solve those patient's clinical problems with 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 is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

chief complaint
A 38yrs old women daily worker by occupation came to the opd with the chief complaint of pain in the right upper abdominal  since 13days
History of present illness
Patient was apparently asymptomatic 13days back then she developed pain in the right upper abdomen, insidious in onset and associated with faulty meal 
h/o Dyspepsia, indigestion, bleeding
No h/o nausea , vomiting, burning micturation, constipation, early sariety , no similar c/o pain since 10yrs back
History of past illness
Not a k/c/o HTN DM thyroid disorders TB hysterectomy done 10yrs back
Treatment history
Hysterectomy done 10yrs back
Personal history
Married
Occupation-daily worker(farm and construction) 
Appetite-normal
Bowel movements-regular
Micturation- regular
Known Allergies-no 
Habits- no habits
Family history
No family history
Physical examination
Temperature -Afibrile
Bp-120/80mm hg
Pulse rate- 86 bpm
Respiration rate- 16 per min
Spo2-99%
GRBS - 126 mg%
Cardiovascular system
Cardiac sounds s1 s2 
Respiration system
Dyspnoea-no
Position of trachea- central
Breath sounds - vesicular
Investigations











Treatment

Inj. TAXIM 1gm 

Ryles tube No14

Urobag 

Foleyi no1

Lignocaine gel












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