1601006032 LONG CASE

 

Long case - GM 1601006032


1601006032

A 65 year old female, resident of narketpally, who is a home maker, came to the hospital with chief complaints of 
1. Fever since 9 days
2. Pain abdomen, vomitings, loose stools since 8 days

History of presenting illness:
Patient was apparently asymptomatic 9 days back. Then she suffered from fever, which was sudden in onset, low grade, associated with chills and rigors, relieved by taking medication. No history burning micturition or increased frequency of micturition.

She developed pain in the lower abdomen 8 days back, which was sudden in onset, cramping type, aggavates with food intake, Relieved by taking medication.

History of vomitings 8 days back.
- 3 episodes/day
- non projectile
- non bilious
- content: food particles

History of loose stools 8 days back.
- 6 episodes/day
- large volume
- watery
- no mucus or blood in the stools

History of increase in thirst and dryness of mouth.
 Vomitings and loose stools subsided with medication.

Past history:
- Known case of Diabetes mellitus and Hypertension since 8years and on medications metformin+vildagliptin and telmisaratan.
- No history of asthma, TB, epilepsy, CAD, thyroid disorders, stroke.

Family history:
- No similar complaints among family members.
- No history of asthma, TB, epilepsy, CAD, thyroid disorders, stroke, diabetes, hypertension.

Personal history: 
- Diet : mixed
- Appetite: decreased
- Sleep: disturbed due to abdominal pain and loose stools
- Bladder habits: regular
- Addictions: consumes toddy occasionally

General examination:
- Patient is conscious, coherent, co-operative
- Moderately built and nourished

- Pallor: present
- No icterus, clubbing, koilonychia, lymphadenopathy, edema.

Vitals: 
Temperature: afebrile

B.p: 110/80 mm Hg
RR: 18 cpm
PR: 80 bpm
O2 saturation: 96%

Abdominal examination:
Inspection:
- generalized distention/ fullness of abdomen is seen
- umbilicus: normal (inverted)
- skin or surface of abdomen: stretch marks (stria) are seen
- all quadrants moving equally on respiration
- no visible pulsations, visible peristalsis, distended veins





Palpation:
- no local raise of temperature
- mild tenderness in the right iliac fossa
- no palpable mass per abdomen
- no guarding and rigidity

Percussion:
- dullnote: all over the adomen
- shifting dullness and fluid thrill: absent

Auscultation:
- bowel sounds: heard

Respiratory system:
- bilateral air entry: present
- vesicular breath sounds heard all over the chest
- no added sounds

Cvs: 
- S1, S2 heard
- Apex beat: left 5th intercostal space in the mid clavicular line.
- No murmurs.

CNS:
- Gait: normal
- Sensory and motor systems: normal
- Reflexes: intact



Provisional diagnosis: Acute gastroenteritis

Differential diagnosis: 
- Inflammatory bowel disease
- Food poisoning

Treatment:
- Iv fluids (normal saline)
- inj. Monocef
- inj. Ondansetron
- Tab. Sporolac
- inj. Tramadol
- inj. Optineuron
- inj. Human actrapid insulin
- inj. NPH


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