40 yr Old female with CHOLELITHIASIS.

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 40year old female patient presented to the OPD complaining severe pain in the abdomen region since morning (25/02/2022)

CHEIF COMPLAINTS:-

Patient was apparently asymptomatic se

C/o pain abdomen since 2 years.

She is a housewife and she was detected 4 years earlier. But the pain started getting worse since 2 years. 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, CVA.

PERSONAL HISTORY:-

Appetite- Normal

Diet- Mixed

Bowels 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.

TREATMENT HISTORY:- Non Significant

GENERAL EXAMINATION:-

Patient is conscious,coherent,cooperative.

Vitals at admission:-

Temperature:- Afebrile

Pulse rate :-80/min.

Respiration rate:-12/min.

BP:- 110/80 mmHg.

SpO2:- 98%

SYSTEMIC EXAMINATION:-

Cardiovascular systems:- S1 S2 heard, No murmurs.

P/A soft :-  Tenderness in right hypochondria.

Respiratory system:- No rigidity

Breath sounds -vesicular.

Abdomen:-

Tenderness,

Bowel sounds-Yes 

PLAN OF CARE:-

Laproscopic cholecystectomy 

DRUGS REQUIRED FOR GENERAL ANESTHESIA:-

Preanesthetic assessment:-

INVESTIGATIONS:-

ECG REPORT:-

COMPLETE URINE EXAMINATION :-

COMPLETE BLOOD PICTURE:-

BLOOD GROUPING AND Rh TYPE:-

BLOOD- SUGAR RANDOM:-

LIVER FUNCTION TEST

RENAL FUNCTION TEST