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

April 13, 2023

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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