19 yr pt came with c/c of headache since 1 week H/o vomiting since 2 days

19 years old patient came to Opd with chief complaint of headache since 1 week H/o of vomiting 2days back


This is an a online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan


The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitt.

Chief complaints:
19 f with chief complaints of 
Headache since 1 week
C/o vomiting 2 days back
C/o heaviness of chest since 2 days
C/o giddiness since 2 days 2 episode


19F intermediate student preparing for Btech entrance who lives in hostel presented with easy fatiguability, malaise and SOB on exertion since 10 days Vomiting and loose stools 7 days back and H/o grey coloured stool since 1 week.she noticed few drops of fresh blood during defecation.


Hopi:

•Patient was  apparently Asymptomatic I month back, then she had 2 episodes of vomiting , non projectile, non bilious, food particles content.symptomatically a/w headache,
History of bleeding per rectum 1 episode - today
Headache - unilateral,throbbing type,non - radiating, ( - )photophobia,( - )phonophobia
Heaviness of chest: not associated with food intake, not associated with exertion 

Past history:-

No similar complaints in the past

Not a know case of DM,ASTHMA,HTN,EPILEPSY,TB

Personal history

Diet: vegetarian 
Appetite: decreased 
Bowel and bladder movements: decreased 
Appetite : decreased
Sleep : adequate 
No aditions

Nutritional history:
Morning - 
tiffen -idly,dosa,bonda,poori+chutney 
Afternoon - sambar,curry,curd + rice
No snack
Night- curry, pickle,curd rice
Fruits - occasionally,
Vegetarian

Menstrual history: 3days/30 days,no clots,pain
H/o of irregular menstrual cycle
Menarche:17y
On examination:-
Pt is C/C/C well oriented to Time ,place and person 

Pallor present

NO=icterus,cyanosis,clubbing,or generalised lymphadenopathy 
afebrile

Bp 110/70
PR -104bpm
Rr- 22cpm
Temp-98.6f
Input/output-600/450 ml
Grbs-107mg/dl

CVS-S1S2 heard

R/S - BAE +

CNS-NFND
 

P/A  

Inspection:

Shape of abdomen normal

Umbilicus -central and inverted

No visible scars,sinuses,dilated veins

Hernial orifices normal 



Palpation -no local rise of temperature 

 Tenderness in right iliac region

No guarding,rigidity,rebound tenderness 

No hepatomegaly,spleenomegaly



Percussion-Resonant 


Liver span- normal

Auscultation-

Bowel sounds +


INVESTIGATION
DAY 1
Serology: negative

Hemogram:
Ultrasound:

CUE
Provisional diagnosis:
Iron deficiency anemia

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