28 yrs old with ACID PEPTIC DISEASE QITH VAGINITIS WITH PRIMARY INFERTTILITY WITH CERVICAL SPONDYLOSIS

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This Elog also reflects my patient centered online learning portfolio.
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 a diagnosis and treatment

Chief complaints::
 A 28 yr old female with 
c/o chest pain since 2yrs
Neck pain since 1yr
B/l knee pain since 1yr

History of present illness::
Patient was apparently asymptomatic 2yr ago then developed chest pain which was insidious in onset gradually progressive 
Pain was radiating to left  upper limb
Retrosternal
No H/o palpitations and sob
C/o nech pain radiating to b/l upper limbs aggrevated during work relieved after resting
Pain when moving head from side to side
Pain of left knee with H/O TRAUMA one yr ago
NoH/o fever,vomitings,loose stools,pain abdomen
H/o white dischargeper vaginum since 8 yrs
Foul smelling and intermittent
 and decreased when using medications
H/o in ability to concieve since 10 yrs
No h/o irregular mensturation

Past history::
H/o Thyroid disorders since 8yrs on medication irregularly using
Not ak/c/o TB,HTN,DM,ASTHMA,CVD,CAD

Family history::
 Not significant

Personal history::
 
Diet:mixed
Sleep ::   adequate
Appetite:: normal
Bowel and bladder:: regular
Addictions::no addictions
General examination::

After taking consent patient examined in a well lit room
Patient was conscious coherent cooperative 
Well oriented to time ,place ,person
Moderate built, nourishment moderate

No pallor
No icterus
No Lymphadenopathy
No cyanosis
No clubbing
Edema present -pitting type


Vitals

Temperature::98.3f
PR-98bpm
Bp-120/80 mmhg
RR--18cpm

Local examination::
Respiratory system::
Inspection::

B/L symmetrical 
Trachea appears to be central
Supraclavicular and infraclavicular hallowing absent
Expansion of chest equal on both sides
No crowding of ribs 
No drooping of shoulder
Wasting of muscles absent
No scoliosis ,kyphosis
No sinuses,scars,engorged veins

Palpation::

No local rise of temperature
All inspectory findings confirmed
Trachea central
Apex beat felt in 5th ICS in mid clavicular line

Percussion::

Direct : over clavicle and manubrium sternum
Indirect ::::

                                             RT.           LT .

Supraclavicular.         Resonant.    Resonant
Infraclavicular.           Resonant.     Resonanat
Mammary.                  Resonant.     Resonant
Axillary                        Resonant.      Resonant
Infraaxillary.                Resonant       Resonant
Suprascapular.           Resonant.      Resonant
Interscapular.             Resonant       Resonant
Infrascapular.             Resonant        Resonant

Auscultation::

 B/L air entry present
 On auscultation:: NVBS


PER ABDOMEN::
Inspection..

Shape of abdomen...scaphoid
Umbilicus..inverted,central located
No sinuses or scars on abdomen

Palpation::

No rise in temperature
No Tenderness present
No palpable mass 
No free fluid
Liver not palpable
Spleen not palpable

Percussion::

Dull note on right upper quadrant
No fluid thrill
No shifting dullness

Auscultation::

Bowel sound heard:

Cardio vascular system:
Jvp -not raised
Apex beat felt in 5h ICS in mid clavicular line
S1s2 heard
No murmurs

Central nervous system::
Speech normal
Cranial nerves intact
Sensory and motor system: normal
Reflexes.normal

Investigations::
Treatment::
T.pan 40mg po/od 
T.ultracet 1/2 po/Tid 
T mvt




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