25yr old female with CHOLELITHIASIS

25 yr old female with CHOLELITHIASIS

February 28

THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-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.

A 25year old female patient presented to the OPD complaining severe pain in the abdomen region since morning (26/02/2022)

CHEIF COMPLAINTS:

Patient complaints abdomen pain 

She is a working women and she was detected 3 months earlier.so she has been medicated under local doctor provision.

HISTORY OF PRESENT ILLNESS:-

Patient came with bloating and then developed abdomen pain.

HISTORY OF PAST ILLNESS:-

Not a k/c/o DM, HTN, TB, BA, CAD.

PERSONAL HISTORY 

Married 

Appetite- Normal 

Diet- Mixed

Bowel and bladder- Regular 

Micturition - Normal

Allergies- No

No habits 

FAMILY HISTORY:-

Allergic history:-not known case of allergy 

Not allergic to pollen and any known drugs.

MENSTRUAL HISTORY:-

Age of menarche: 12 years

Any geneacological problems:No

GENERAL EXAMINATION:-

patient is conscious,coherent, cooperative 

Vitals at admission:-

Temperature:- Afebrile

Pulse rate :- 80/min.

Respiration rate :12/min.

BP:-120/69

Spo2:-99%

SYSTEMIC EXAMINATION:-

Cardiovascular system:

Thrills:No

Cardiac sounds: S1 S2 heard,No murmurs.

RESPIRATORY SYSTEM:-

Dyspnoea -No

Wheeze-No

Position of trachea- central 

Breath sounds-vesicular

Abdomen:- Tenderness 

Bowel sounds-No 

DRUGS REQUIRED FOR GENERAL ANESTHESIA:-

Inj Vecuronium-6

Inj Adrenaline-1

Inj Dexamethoxone-1

Diclofenac-1

INVESTIGATIONS:-

ECG REPORT:-

COMPLETE BLOOD PICTURE:-

LIVER FUNCTION TEST:-

SERUM ANALYSIS:-

BLOOD SUGAR-RANDOM:-

TREATMENT:

Laproscopic cholecystectomy