40yr old female with neck pain and severe bloating
Case of 40yr old female with neck pain and severe bloating.
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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.
CHIEF COMPLAINTS
A 40yr old female came to the opd with neck pain since 6 months and severe bloating in abdomen since past 20 days.
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic 20 days ago then she developed severe bloating in abdomen due to indigestion.
Insidious in onset and gradually progressive in nature, intermittent in nature and aggravated on eating. Shortness of breath at nights.
Constipation associated with burning sensation.
Burning micturation.
PAST HISTORY
Not a known case of hypertension, DM, CVA,CAD,TB, asthma.
13yrs ago she had c section
10yrs ago she has undergone hysterectomy
FAMILY HISTORY
No significant family history
PERSONAL HISTORY
Appetite-normal
Sleep-adequate
Diet-mixed
Burning micturation
Bowel movements irregular- constipation
GENERAL EXAMINATION
No signs of pallor,icterus, cyanosis, clubbing, lymphadenopathy and pedal edema.
Pulse:64 bpm
Bp:110/70mm hg
RR:16bpm
Temp:98.6F
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