A 50 year old female with constipation.

 This is an online E log book to discuss our patient's de-identified health data shared after taking his 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 patient's clinical problems with collective current best evidence based inputs. 


JOGAM SAI CHARISHMA
ROLL NO:60

 I've 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 diagnosis and treatment plan.

November 30th, 2021.

Case  :

A 50 year old female came to the OPD with the chief complaints of 
  • Pain abdomen since 3 days
  • Constipation since 2 days.
History of present illness :

  • The patient was apparently asymptomatic 3 days ago when she developed pain abdomen which was insidious in onset and non progressive.
  • The pain was diffuse, squeezing type and non radiating. There are no aggravating and relieving factors.
  • The patient has h/o nausea and 4 episodes of vomiting 3 days ago. Vomitings were non projectile, non bilious and the content was food.
  • The patient also has constipation from 2 days associated with not passing flatus since 1 day.
  • The patient had chest pain 5 days ago, she was given antacid in the local hospital. The pain relieved upon taking medication. 
  • She has associated SOB of grade 2.
History of past illness : 
  • H/o pain abdomen 2 months ago.
  • H/o renal calculi 2 years, managed conservatively.
  • Known case of HTN on irregular medication.
  • Not k/c/o of DM, asthma and epilepsy.
  • She was tubectomised 20 years ago.
  • She underwent hysterectomy 15 years ago
Personal history :
  • Mixed diet
  • Appetite - decreased
  • Sleep - adequate
  • Bladder - increased micturition
  • Bowel - constipation
  • No addictions.
General examination :
The patient was examined in a well lit room after taking consent.
  • The patient is conscious, coherent and cooperative. She is well oriented to time, place and person.
  • She is moderately built and well nourished.
  • No pallor, icterus, cyanosis, clubbing and lymphadenopathy.
Vitals :
  • Temperature - Afebrile
  • Pulse - 77bpm
  • Respiratory rate - 18cpm
  • BP - 140/80 mm Hg  
Systemic examination :
  • CNS - NAD
  • RS - BAE +
  • CVS - S1, S2 heard
Abdominal examination - 
  • On inspection - Scaphoid abdomen, which is moving with respiration. 
  •  On palpation - there is no local rise of temperature. Abdomen is soft. Diffuse tenderness is present but it is more in the Right iliac fossa, hypogastrium and Left iliac fossa. No guarding or rigidity.
Per rectal examination - 
  • Sphincter tone - normal
  • Rectum loaded with hard stool
Provisional diagnosis :

Constipation secondary to paralytic ileus?

Plan of action : 
  • INF N.S @ 75ml/hr.
  • Syp. Dulcolac 10ml PO BD
  • Tab. Buscopan 1 tab PO sos
  • Tab. Pan D 40mg PO OD
  • Soap water enema

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