GEN MED CASE: chief complaints Pain in Right lower quadrant of abdomen since 1week

GEN MED CASE: chief complaints  Pain in Right lower quadrant of abdomen since 1week 

 Student- y.rahul

Batch- 2017

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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.

HISTORY OF PRESENTILLNESS: C/O PAIN IN RIGHT LOWER QUADRANT ABDOMEN  SINCE 1WEEK 

Patient was apparently asymptomatic 

1week back then be developed pain in Right lower quadrant abdomen. Which is spasmodic type intermittent non radiating h/o of fever present which is intermittent reliever on taking Medication H/o vomiting present (immediately after intake of food) which in non bilious non-projectile With food as content , 

PAST HISTORY: At age of 10years 

N/k/c/o DM ,HTN , ASTHMA , EPILEPSY

PERSONAL HISTORY: 

* Diet - Mixed

* Appatite - Normal

* Sleep - Reduced

* Bowel and Bladder - Reduced urination, normal bowel.

* Allergy - None

* Addictions 

- Alcohol - about 90ml per day since his teenage.

- Bedi - 1 packet per day since his teenage.

FAMILY HISTORY: 

No history of similar complaints in the family.

GENERAL EXAMINATION:

The patient is conscious,coherent and cooperative; well oriented to time,place and person.

He is sleeping comfortably on the bed.

He is moderately build and well nourished.

* Pallor - present 

*Icterus- present 

*Clubbing-absent

*Cyanosis-absent

*Lymphadenopathy-absent

*Edema - B/L pitting type present, extending upto the knee.