33 year old female with right lower abdominal pain

 Sep 19th

Hello, I am Y.N.Indu Vaishnavi,a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.

33 year old female resident of west bengal came to opd with lower abdominal pain

CHIEF COMPLAINTS
She came with a chief complaint of pain radiating from groin to right flank region gradually increasing since 3 years.
C/O nausea and vomiting since 3months
C/O no fever

HISTORY OF PRESENT ILLNESS 
Patient is apparently asymptomatic 3 years ago.
Then she developed pain in the right groin region which radiated to right flank region
It was gradually increasing pain.
Aggrevating factors : on walking, or doing heavy work 
Has dull pain during rest.
It severely increased 3 months ago.
She also complaints of nausea and vomiting since 3 months which relieved on medication.
She complaints of burning micturition since 5 days.
C/O dysuria
No white discharge

HISTORY OF PAST ILLNESS 
No HTN/diabetes
She had undergone tubectomy 5 years ago.

PERSONAL HISTORY
Patient is a home maker by occupation
married with 3 kids
Bowel movement is regular
Burning Micturition
Non alcoholic

FAMILY HISTORY 
No significant family history 

PHYSICAL EXAMINATION 

A. GENERAL EXAMINATION

Well built
Well nourished
No pallor

No icterus
No cyanosis
No pedal oedema
No clubbing of fingers
No lymphadenopathy
Mild dehydration

B. VITALS

Temperature - Febrile
Pulse - 92 bpm
Respiratory rate - 17
BP - 110/80
GRBS - 88 mg%

SYSTEMIC EXAMINATION

 A. CVS
- No thrills
- S1 S2 positive
-no cardiac murmurs

B. RESPIRATORY SYSTEM 
- no dyspnoea 
- No wheezing
- central trachea
- vehicular breath sounds 

C. ABDOMEN
-  scaphoid shaped abdomen 
- No tenderness
- No palpable mass
- non palpable liver and spleen

C. CNS
- conscious and coherent
- normal speech

INVESTIGATIONS
1. ECG

2. USG


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