PAIN ABDOMEN UNDER EVALUATION

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A 18yr old married women ,who is labourer by occupation came with 

•C/O Constipation since 1 week

•C/O Pain abdomen since 1 week 

•C/O shortness of breath (grade 3 according to NHYA)since 1 week

•C/O 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

X-ray Erect abdomen:

CHEST XRAY

USG:

2D ECHO 

SOAP NOTES Day 1

S- Pain abdomen decreased

SOB(grade 3)

No active complaints

O- Patient is consious, co-herent, co-operative,

 Pallor +

No icterus,odema, cyanosis, clubbing, lymphadenopathy.

Passed stools 3times from today morning

VITALS :

Temperature - 99.4F

Pulse rate - 86BPM, REGULAR, NORMAL VOLUME

BP -

@8AM-130/70MM OF HG

SPo2 - 98%@RA

GRBS-121mg/dl

SYSTEMIC/ EXAMINATION - 

CVS -S1,S2 Heard

RS-BAE+

CNS-NAD

P/A- Soft,Tenderness in left hypochondrium,epigastrium, left iliac region

Bowel sounds present

A -Pain Abdomen under evaluation

SOAP NOTES Day 2

S-

• Pain abdomen decreased

O- Patient is consious, co-herent, co-operative,

 Pallor +

No icterus,odema, cyanosis, clubbing, lymphadenopathy.

Passed stools 1 time from today morning

VITALS :

Temperature - 99.4F

Pulse rate - 86BPM, REGULAR, NORMAL VOLUME

BP -

@8AM-120/70MM OF HG

SPo2 - 98%@RA

SYSTEMIC/ EXAMINATION - 

CVS -S1,S2 Heard

RS-BAE+

CNS-NAD

P/A- Soft,Tenderness in left hypochondrium,epigastrium, left iliac region

Bowel sounds present

A -Pain Abdomen under evaluation