18 yrs old female patient came to Opd with chief complaint of headache since 1 week H/o of vomiting 2days back

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

Chief complaints:

18 F with chief complaints of 

Headache since 1 week

vomiting 2 days back

Heaviness of chest since 2 days

giddiness since 2 days 2 episode

18F intermediate student preparing for Btech entrance who lives in hostel presented with easy fatiguability, malaise and SOB on exertion since 10 days Vomiting and loose stools 7 days back and H/o grey coloured stool since 1 week.she noticed few drops of fresh blood during defecation.

History of present illness :-

•Patient was  apparently Asymptomatic 1 month back, then she had 2 episodes of vomiting , non projectile, non bilious, food particles content.

History of bleeding per rectum 1 episode - today

Headache - unilateral,throbbing type,non - radiating.

Heaviness of chest: not associated with food intake, not associated with exertion 

Past history :-

No similar complaints in the past

Not a known case of DM,ASTHMA,HTN,EPILEPSY,TB

Personal history :-

Diet: vegetarian 

Appetite: decreased 

Bowel and bladder movements: decreased 

Sleep : adequate 

No addictions

Nutritional history :-

Morning -  idly,dosa,bonda,poori+chutney 

Afternoon - sambar,curry,curd + rice

No snack

Night- curry, pickle,curd rice

Fruits - occasionally,

Vegetarian

Menstrual history: 3days/30 days,no clots,pain

H/o of irregular menstrual cycle

Menarche:17y

On Examination :-

Pallor present -

NO=icterus,cyanosis,clubbing,or generalised lymphadenopathy 

afebrile

BP -110/70

PR -104bpm

RR - 22cpm

Temp-98.6°f

Input/output-600/450 ml

Grbs-107mg/dl

CVS-S1 S2 heard

R/S - BAE +

CNS-NFND

P/A  

Inspection:

Shape of abdomen normal

Umbilicus -central and inverted

No visible scars,sinuses,dilated veins

Hernial orifices normal 

Palpation -no local rise of temperature 

 Tenderness in right iliac region

No guarding,rigidity,rebound tenderness 

No hepatomegaly,splenomegaly

Percussion-Resonant

Bowel sounds +

INVESTIGATION :-

Serology: negative

Hemogram :-

Ultrasound :-

CUE :-

Serum calcium :-

Serum phosphorous :-

Stool examination :- Negative

Chest xray:-

2D Echo:-

Treatment :-

1.inj. zofer4mg/iv/sos

2.inj.iron sucrose200 mg in 100 ml ns over. 2 to 3 hrs

3.iron rich diet

4.tab dolo 650 mg p/o 

5.syp.cremaffin 30ml/po

6.High fiber diet

7.anobliss ointment L/A

8.Sitz bath (betadine)

9.plenty of oral fluids