A 30Y/F with abdomen pain since 3months

 March 08, 2022 

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

CHEIF COMPLAINT:
30Y/F and day worker by occupation came to OPD with C/O pain in abdomen since 3 months with no history of Vomitings,nausea and fever

HOPI:
Patient was apparently asymptomatic 3 months back.
Then one day she developed intermittent pain in right hypochondrium.
She went to a local hospital, symptoms did not subside and then came to our casuality where she was diagnosed with cholelithiasis
And there is no history of Vomitings and nausea.
Normal routine of the patient:
She used to get up at 6 in the morning, used to have a cup of tea and did some household work, then at 8 she used to have her breakfast(rice) then go for farming, she used to have lunch at 2 which is rice again. She used to return home by 6 in the evening then she used to freshen up and have dinner at 8 PM(rice) and sleep after that.

PAST HISTORY:
Not a K/c/o DM , HTN , BA , Thyroid disorder and Epilepsy.

 PERSONAL HISTORY:
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel and bladder movements - regular
She have an habit of drinking alcohol occasionally.

FAMILY HISTORY:
No similar history in the family

GENERAL EXAMINATION:
-Patient is conscious,coherent and cooperative at the time of joining 

-No pallor 

-No icterus

-No lymphadenopathy 

-No cyanosis 

-No clubbing of fingers

-No edema of feet

-No malnutrition

-No dehydration 

 ▪️VITALS:
Temperature - 98.3 F
Pulse rate - 70 bpm
Respiration rate - 16 cpm
BP - 120/80 mmhg
Spo - 99%

SYSTEMIC EXAMINATION:

▪️CVS

-no thrills 

-no cardiac murmurs

S1&S2 sounds are heard

▪️RESPIRATORY SYSTEM 

-BAE present

▪️CNS

-Patient is conscious
-Speech is present
-Normal reflexes
 
INVESTIGATIONS:
SURGICAL PROFILE




DIAGNOSIS:
Cholelithiasis

TREATMENT:
Laproscopic Cholecystectomy


 


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