A 54 year old female patient came to general medicine OPD with the chief complaints of increased frequency of vomiting

GENERAL MEDICINE E-BLOG 


Hi, I am M. Sohith Mahadeva Reddy of 5th semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.



The patient’s consent was taken verbally prior to history taking and examination of his/her condition.


A 54 year old female patient farmer by occupation came to medical OPD with chief complaints of
Vomiting since 2 years
Associated with headache, unconsciousness and neck pain.



HISTORY OF PRESENTING ILLNESS



Patient was apparently asymptomatic 2 years ago.
Projectile vomiting since 2 years which increased since 6 months.
Frequency of vomiting was one per one month for two years which increased to one per 15 days since 6 months.
Vomiting is non bilious, non blood stained, watery with food contents,
Vomiting is preceded by nausea, headache, and giddiness and succeeded by unconsciousness and syncope.
Also associated with sweating and giddiness and not associated with fever.
Headache was localised to frontal lobe, non radiating and throbbing type. It was not relieved by medication and postural changes. It was not associated with photophobia and phonophobia. 
She has neck pain which is bilateral, non radiating, not relieved by medication and postural changes, It was not associated with neck stiffness.

HISTORY OF PAST ILLNESS


History of trauma to head 6 years ago.
Treated with suture and medications.
History of hysterectomy 10 years ago due to tumour.
No history of other comorbidities.

FAMILY HISTORY


no significant family history

PERSONAL HISTORY


Married 
occupation: farming
Diet: mixed
Appetite:normal
Sleep: inadequate
Bowel: regular
Bladder: normal micturition
No known allergies
Addictions: occasional intake of palm wine


GENERAL EXAMINATION 

Physical examination 

conscious and coherent
pallor absent 
No icterus
No lymphedemopathy
No clubbing of fingers
Edema absent
No malnutrition
No dehydration

VITALS
temperature: 98.4°F
Pulse rate: 74 bpm
Respiration: 20/min
BP: 130/70

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