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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