General medicine blog 1

 GENERAL MEDICINE BLOG 1 

Chief complaint:

A 37 year old female who is a farmer by occupation and resides in Miryalguda came to the OPD with chief complaint of back pain from the last 6 months. 


History of present illness: 

The patient was apparently asymptamatic 6 months ago then she developed back pain on her left side. A week after her back pain developed, she experienced abdominal pains in the umbilical region. The type of pain she experienced was dragging type of pain that was radiating from the back to the front. 

She had no aggregating or relieving factors.

She also experienced upper limb weakness at the point of time. 

She visited a local clinic where in some medication was given to her. 

The pain gradually subsisted on using the medication for a month, then she developed on and off fever which was associated with vomitings.

She vomitted 2 times a day whenever she had fever. Her vomitings were projectile and yellow in color. 

Then she consulted a local doctor who prescribed her medications, but upon repeated discomfort she deceived to visit kamineni. 


Past history 

The patient is a known case of diabetes mellitus for the last 17 years. She takes insulin pills twice daily. 

Family history 

Her mother, brother and sister are all known cases of diabetes mellitus.


Surgical history 

She had a C section done for her third child in 2004, and had a tubectomy done at the same time . 


Personal history 

Diet: mixed 

Sleep: adequate 7-8 hours of sleep 

appetite: increased 

micturation: increased 

Thirst: increased 

Bowel movements: regular 

Addictions: she used to consume beer 17 years ago before she got diagnosed with diabetes 

Non smoker 


Physical examination

Conscious

 coherent

cooperative 

Built and nourishment: moderate


Vitals 

Pulse: 55 beats per minute, rhythm is irregular

Respiration: 16/ min 

Temperature: normal 


General examination 

Pallor present 


No icterus 

No clubbing of fingers 

No cyanosis 

No lymphadenopathy 

Pedal oedema present 


 










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