a case of 33 yr old female

This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

Pt is a 33 yr old female who lives in west bengal and is a  housewife.

She has come with chief complaints of RT. Loin pain extending to groin since past 3 yrs.

HOPI

pt.was asymptomatic 3 yrs ago, then developed pain which was extending from RT. Loin to groin.
 The pain was insidious in onset, is intermittent, is of tingling type and increases on exertion 
( doing household work)
Initially the pain was bearable and thus it was ignored.
 Then The pain progressively increased over time(3 months) and was associated with nausea and vomiting. It was  relieved by taking medication. 

2 1/2 years ago- visited  doctor due to an increase in the severity of the pain.  was prescribed medication, which reduced the pain.  Used medication for a month. On discontinuing the medication after 15 days the pain aggravated.

She then took homoeopathic medicines for 1 year.

1 year ago she went to multiple doctors, but no permanent solution was found.
 she also has complaints of burning micrurition.

Past history
She has not k/c/o of DM HTN TB asthma and epilepsy.
Surgical history of tubal ligation done 5 yrs ago after giving birth to the third child.
2 yrs later (3yrs ago ) pain started.
Appetite: reduced due to pain
Diet:mixed
Bowel and bladder:regular 
Sleep: adequate 
No significant family history
No addictions or allergies.

MENSTRUAL HISTORY

Age of menarche - 11 years

3 days duration / 30 days cycle .

Regular, not associated with pain and clots.

OBSTETRICS HISTORY

The patient got married in 2005

3 children - Delivered by normal vaginal delivery.


On admission.
Patient is conscious coherent cooperative 
BP: 110/80mmhg
PR:76
RR: 20 cpm
Temp: afebrile 
CVS:S1 S2+
RS: BAE+ 
CNS: NAD
Speech normal 

REFLEXES-
                        RT.  LFT
BICEPS-         ++.   ++
TRICEPS-.       ++.  ++
SUPINATOR-.  ++.  ++
ANKLE. -.        ++.   ++
KNEE-.             ++    ++


 Investigations






33yr old female 2d echo

16/9/22 obsgyn cross consultantation notes 


Diagnosis 
Chronic non cyclic abdominal pain 
Treated for pelvic inflammatory disease on discharge


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