PAIN ABDOMEN UNDER EVALUATION
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A 18yr old married women ,who is labourer by occupation came with complaints of
Constipation since 1 week
Pain abdomen since 1 week
shortness of breath (grade 3 according to NHYA)since 1 week
Fever since 1 week
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 week ago,then she developed burning micturition which subsided after one week on taking medication.
Pain abdomen since one week , insidious in onset , gradually progressive, squeezing type , associated with nausea . Abdominal distension was present which reduced after taking medication given by local doctor (according to patient).
•C/O Constipation and obstipation also present
•C/O shortness of breath (grade 3)not associated with orthopnea and PND
•C/O Fever since 1 week, insidious in onset, gradually progressive, associated with headache and bodypains ,not associated with chills and rigor , subsided on taking medication
PAST HISTORY:
Not a K/C/O DM,HTN,BA, EPILEPSY
PERSONAL HISTORY:
SLEEP: INADEQUATE
APPETITE: DECREASED
DIET :MIXED
BOWEL AND BLADDER MOVEMENTS-
CONSTIPATION SINCE 1 WEEK
MENSTRUAL HISTORY:
•LMP-16/4/22
•AOM:11YRS
•PREVIOUSLY IRREGULAR CYCLES ,
AFTER TAKING MEDICATION,CYLCES ARE REGULAR
•BLEEDS 4-5 DAYS /CYCLE.
•ASSOCIATED WITH PAIN AND CLOTS
MARITAL HISTORY:
Married life of 1.5 years
Non-consanguinous marriage
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS, COHERENT,
COOPERATIVE
VITALS:
TEMP-98.8
BP- 110/70mmhg
PR -98bpm
SYSTEMIC EXAMINATION:
CVS -S1,S2 Heard
RS-BAE+
CNS-NAD
P/A- Soft,Tenderness in left hypochondrium,epigastrium, left iliac region
Bowel sounds present
INVESTIGATIONS:
BGT: B POSITIVE
RBS:#86
BLOOD UREA :13
SERUM CREATININE:1.0
SERUM SODIUM: 138
SERUM POTASSIUM:4.0
SERUM CHLORIDE:98
COMPLETE URINE EXAMINATION:
PALE YELLOW,CLEAR , ACIDIC
PUS CELLS:3-4
EPITHELIAL CELLS:2-3
ALBUMIN:NIL
SUGARS:NIL
HEMOGRAM:
Hb:#9.1
TLC:#11,000
N/L/E/M/B:74/15/05/06/00
PCV:#28.7
MCV:#69.2
MCH:#22
PLATELET COUNT:2.52
PERIPHERAL SMEAR
RBC :Mild Anisopoikilocytosis with Microcytic Hypochromic and Few Pencil froms seen
WBC : With in normal limits
PLATELET : Adequate
LDH:230
SERUM LIPASE:44
SERUM AMYLASE:107
URINE PREGNANCY TEST: NEGATIVE
SEROLOGY: NEGATIVE
LFT:
TB:0.69
DB:0.20
AST:17
ALT:17
ALP:300
TP:5.9
ALBUMIN:#3.47
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