66 yr female with abdominal pain, loose motions and generalized weakness

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I have 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

66 yr old female resident from cherlapally came to opd with chief complaints of

1.Abdominal pain since 2 yrs

2.Loose motions since 2 yrs

3.Generalized weakness since 1 yr

History of presenting illness:

Patient was apparantly asymptomatic 4 yr back then she developed constipation for 1 month ( once in 2 days) which was associated with blood in stool,for which she admitted in hospital and undergone surgery for hemorrhoids.

After 2 yrs she developed loose motions 2-3 times a day which was watery ,mucoid, foul smelling,Non blood stained.It is aggravated by dal and tomato and relieved by taking medication.

History of tenesmus, bloating most oftenly associated after meals

History of abdominal pain in epigastric region which is insidious in onset ,sharp radiating to back.It is aggravated after taking meals and relieved by taking butter milk or medication.

History of generalized weakness since 1 yr

History of nausea and Vomiting (2 episodes per day)intermittently since 10 days which was insidious in onset ,non projectile,non bilious and contents are food particles.It is associated with headache (diffuse type).It is relieved on taking medication.

History of indigestion and heart burn

History of weight loss since 2 yrs

No history of dysphagia, hematemsis,jaundice

No history of hematochezia,melena

No history of fever, cough ,cold .

No history of chest pain , shortness of breath 

Past history:

 Not a k/c/o DM ,HTN,TB, Asthma, Epilepsy, thyroid disorders

Family history: 

No significant family history 

Personal history:

Diet : Mixed

Appetite:Normal

Sleep: disturbed

Bowel and bladder movements: Irregular

No addictions 

General examination:

Patient is concious,coherent and cooperative

Moderately built and nourished

Temp: afebrile

PR:80 bpm

RR:16cpm

BP: 140/90 mmHg

Pallor present

No icterus ,cyanosis,clubbing,lymphadenopathy and edema

Systemic examination:

Per Abdomen:

Inspection:

Shape - flat

Flanks - free

Umbilicus - inverted

All quadrants moves equally with respiration 

No engorged veins, visible pulsations

Hernial orifice are free

Palpation:

No local rise of temperature

Abdomen is soft and non tender

No palpable spleen and liver

No other palpable masses

Percussion:

Resonant 

Auscultation:

Normal bowel sounds heard

CVS:

Jvp not raised 

Inspection:

Shape of chest - elliptical

No visible pulsations

No engorged veins 

Apical impulse not visible

Palpation:

Apex beat present over the left 5th intercostal space medial to midclavicular line

No parasternal heave

No precordial thrill

No dilated veins

Auscultation:

S1 S2 heard ,No murmurs 

Respiratory system:

Upper respiratory tarct - normal

Lower respiratory tract:

Inspection:

Chest bilaterally symmetrical,

Shape- elliptical

Trachea- midline

Palpation:

Trachea is central

Normal chest movements

Percussion: in sitting postion

                                                 Rt.                  Lt

Supraclavicular. N(resonant).                 N

Infraclavicular. N.                                      N

Mammary region. N.                                 N

Axillary region. N.                                     N

Infra axillary region. N.                           N

Supra scapular region. N                          N

Interscapular region. N.                             N.  

Infrascapular region. N.                             N

Auscultation:

Normal vesicular breath sounds

No added sounds

Vocal resonance is normal

CNS :

Higher motor functions - intact

Cranial nerves - intact

Motor system:

            Rt- UL. LL.                    Lt- UL. LL

Bulk - normal N.                            N. N 

Tone - N. N.                                     N. N

Power - 5/5. 5/5.                            5/5. 5/5

Reflexes:         

                            UL.                        LL

Biceps. 2+.                                        2+

Triceps. 2+.                                      2+

Supinator. 2+.                                  2+

Knee 2+.                                           2+

Ankle. 2+.                                         2+

 Sensory system: intact

Co ordination is present 

Gait is normal

No Cerebellar signs 

No signs of meningeal irritation 

Investigations:

Provisional diagnosis:

Chronic gastritis