A 58 year old female with pain abdomen and generalized weakness
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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.
A 58 year old female from north bengal, teacher by occupation, came with complaints of pain abdomen and generalized weakness and anxiety.
HOPI :-
Pain in right hypochondrium and epigastrium, non radiating not associated with fever, vomitings and diarrhea.
Aggravated by food intake and relieved with time.
H/o Dyspepsia since childhood
Chronic weakness since 10 years on diagnosis with hypothyroidism
PAST HISTORY
In 2019, pt had vomitings and loose stools along with right hypochondriac pain.
She was diagnosed with cholelithiasis and was operated for it during her first admission on 26 November 2019.
She was also diagnosed with OCD in 2019.
She has hypothyroidism since 10 years and is on thyronorm 37.5 mcg 5/7 and 50mcg 2/7.
No history of DM, HTN, CAD, epilepsy, TB, asthma.
PERSONAL HISTORY-
Sleep- adequate
Diet - puffed rice as breakfast, mixed diet
Appetite - normal
Bowel and bladder movements - normal
No addictions
FAMILY HISTORY-
Mother has osteoarthritis.
Pt complains of pain in right knee after injury- traumatic osteoarthritis?
TREATMENT HISTORY-
Thyronorm 37.5 mcg 5/7 and 50 mcg 2/7
Tab Pan 40 mg PO/OD
Tab MVT PO/OD
GENERAL EXAMINATION-
Pt is conscious, coherent and cooperative.
No pallor, icterus, clubbing, cyanosis, lymphadenopathy and edema
VITALS -
Temp- afebrile
BP : 130/80 mm hg
PR: 84 bpm
RR : 20/min
SYSTEMIC EXAMINATION -
CVS : s1 s2 heard
RS : BAE +, NVBS heard
P/A : soft, tenderness present in right hypochondrium
Bowel sounds heard
CNS : NAD
DIAGNOSIS-
acid peptic disease
Post cholecystectomy ( 2 years back)
Hypothyroidism since 10 years.( hashimotos)
OCD since 2 years
> Dermatology referral in view of subcutaneous nodule near right supraorbital ridge.
> Psychiatry referral in view of anxiety and OCD.
DISCHARGE SUMMARY
Discharge Date
Date: 17/9/21
Ward: Super speciality ward
Unit: GM 2
Name of Treating Faculty
DR. JANCY ( INTERN)
DR. DURGA KRISHNA ( PGY2)
DR. SHASHIKALA ( PGY2)
DR. USHA ( PGY3)
DR. RASHMITHA ( PGY3)
DR.RAKESH BISWAS ( HOD)
Diagnosis
MILD DEPRESSION WITH ANXIETY SYMPTOMS
ACID PEPTIC DISEASE
POST CHOLECYSTECTOMY ( 2 YEARS BACK)
HYPOTHYROIDISM SINCE 10 YEARS.( HASHIMOTOS)
OCD SINCE 2 YEARS
Case History and Clinical Findings
A 58 YEAR OLD FEMALE FROM NORTH BENGAL, TEACHER BY OCCUPATION, CAME WITH COMPLAINTS OF PAIN ABDOMEN AND GENERALIZED WEAKNESS AND ANXIETY.
HOPI
PAIN IN RIGHT HYPOCHONDRIUM AND EPIGASTRIUM NON RADIATING, NOT ASSOCIATED WITH FEVER, VOMITINGS AND DIARRHOEA, AGGRAVATED BY FOOD INTAKE AND RELIEVED WITH TIME.
H/O DYSPEPSIA SINCE CHILDHOOD
CHRONIC WEAKNESS SINCE 10 YEARS ON DIAGNOSIS WITH HYPOTHYROIDISM.
PAST HISTORY -
IN 2019 PATIENT HAD VOMITINGS AND LOOSE STOOLS ALONG WITH RIGHT HYPOCHONDRIAC PAIN
SHE WAS DIAGNOSED WITH CHOLELITHIASIS AND WAS OPERATED FOR IT DURING HER FIRST ADMISSION ON 26 NOVEMBER 2019.
SHE WAS ALSO DIAGNOSED WITH OCD IN 2019 AND TOOK TREATMENT FOR 4 MONTHS.
SHE HAS HYPOTHYROIDISM SINCE 10 YEARS AND IS ON THYRONORM 37.5 MCG 5/7 AND 50 MCG 2/7
PATIENT COMPLAINS OF PAIN IN RIGHT KNEE AFTER INJURY ? TRAUMATIC OSTEOARTHRITIS
NO H/O DM, HTN, EPILEPSY, CAD, TB, ASTHMA
PERSONAL HISTORY
SLEEP - ADEQUATE
DIET - MIXED DIET
APPETITE - NORMAL
BOWEL AND BLADDER MOVEMENTS - REGULAR
NO ADDICTIONS
FAMILY HISTORY -
PATIENT'S MOTHER HAS OSTEOARTHRITIS
GENERAL EXAMINATION -
PATIENT IS CONSCIOUS, COHERENT AND CO OPERATIVE
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY AND EDEMA
VITALS
TEMP - AFEBRILE
BP - 130/80 MM HG
PR - 84 BPM
RR - 20 CPM
SYSTEMIC EXAMINATION -
CVS - S1, S2 HEARD, NO THRILLS , NO MURMURS
RS - BAE +, NVBS HEARD
P/A SOFT, TENDERNESS PRESENT IN RIGHT HYPOCHONDRIUM, BOWEL SOUNDS HEARD
CNS- NAD
Treatment Given(Enter only Generic Name)
1) THYRONORM 37.5 MCG 5/7 AND 50 MCG 2/7
2) TAB PAN 40 MG PO/OD
3) TAB MVT PO/OD
4)PSYCHO EDUCATION AND BRIEF PSYCHOTHERAPY
Advice at Discharge
1) THYRONORM 37.5 MCG 5/7 AND 50 MCG 2/7
2) TAB MIRTAZ 50MG EVERY NIGHT FOR 20 DAYS
3) TAB CLONAZEPAM 0.25 MG SOS
4) SLEEP HYGIENE
5) RELAXATION AND DIVERSION TECHNIQUES AS EXPLAINED
Follow Up
REVIEW AFTER 3 MONTHS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS.
In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: 08682279999 For Treatment Enquiries
Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
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