PATIENT DATA

'What about my baby?'

Problem Synopsis

Mrs Leong Tring is a 41 year old woman who presents to the GP complaining of nausea and vomiting in the mornings for the last 4 weeks.

The GP considers the major causes of vomiting ...

  • GI irritation, poisons
  • GI obstruction
  • Inflammation of abdominal organs
  • Metabolic/hormonal
  • Central nervous

He rules out obstruction as being unlikely in view of the time scale (not acute onset, too drawn out). He asks questions and receives the following answers:

  • Diet - no change in recent years, eats traditional South East Asian foods for the most part
  • Drugs/Medications - takes no medications at all, no drugs
  • Abdominal inflammation - no abdominal pain, tenderness, bloating, discomfort, except when vomiting
  • Metabolic/hormonal - no skin infections, urine infections etc; has noted recent missed periods
  • CNS - does not suffer from migraines, no neurosis, no vertigo, no fits or faints, no balance problems

What is the presumptive Diagnosis?

What do you need to do to confirm this?

When you have a plan PROCEED

 


Web demo notes:

This is the sort of information that a practitioner would normally elicit in respect of a suspected malfunction of the body organ-system in question in this case. This starts to form the structured enquiry pattern in the mind of the student. Alongside this the student will have opportunities to practice their history-taking skills in nearby clinics.

The student will identify abnormal findings and refine their hypothesis list in the light of that information, so developing their clinical reasoning skills. Some abnormalities they come across will be new, or will not readily be explained with the knowledge they currently have, and so will generate new learning topics and goals for study after the session.

The student should now identify their lead hypotheses and specify what examination they would carry out on the patient, what they would expect to find and what those findings would mean

In this case the lead hypothesis would be that the lady is pregnant, and the key further history and examination items would concentrate on:

  • recent menstrual and contraception history
  • abdominal examination seeking a palpable uterus
  • pregnancy test

Now click on the PROCEED button below to continue.

What is the presumptive Diagnosis?

What do you need to do to confirm this?

When you have a plan PROCEED