General medicine e-log

 A 35 y old female came to opd

With chief complaints of abdominal pain,fever,nausea 


HOPI:

Patient was apparently asymptomatic 6 days back.

Then she developed abdominal pain which was severe and went to local hospital for treatment and then she developed fever.

She was a known case of renal calculus since 1 year.on CT examination increase in size of renal calculus is seen..she was then referred to our hospital 


Patient came to surgery department with complaints of abdominal pain since 6 days,

Pain was present throughout the day,it was radiating to back on the right side and it was radiating towards thigh on the left side.


Fever was present since 4 days 

Not associated with vomitings,loose stools.

 She had episodes of black coloured urine and stools on mon evening 

She had a platelet count of 6000 

Then she had a blood transfusion.


Past history:

Not a known case of diabetes,asthma,TB

She was diagnosed with renal calculi 1 year back .

She was diagnosed with arthritis in 2017 

For which she used medication for 3 years.


Personal history:


Mixed diet

Decreased appetite since 6 days

Sleep adequate 

Bowel and bladder movements are regular 


General examination 

No pallor

No icterus

No cyanosis

No lymphadenopathy










Systemic examination:


Cvs: S1,S2 heard ,no murmurs


Respiratory system:

No dyspnea 

No wheeze

Position of trachea is central 

 CNS:

Patient is conscious and coherent.

Motor and sensory system -normal


Abdomen :

Inspection-

 Distended

Scaphoid in shape

No visible masses,sinuses,no dilated veins

All quadrants are moving equally with respiration.

Palpatoin-


Soft,tenderness present in epigastric region ,No palpable mass,no organomegaly,

No rise in temperature ,

Percussion-

Liver dullness not obliterated

Auscultation -

Bowel sounds are heard.


Investigations:







24/9/22




Treatment:

 1)IV fluids -NS

                  RL

 2) inj pan 40 mg OD

3)inj zofer 4mg IV

4)inj neonol 1g iv

5)tab paracetamol 650mg 

6)inj optineuron


Diagnosis:

Undifferentiated CTD??  With 

Thrombocytopenia hepatitis 

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