1601006044 SHORT CASE

 

1601006044: SHORT CASE




"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment. 



A 25 year old female patient , tailor by occupation, hailing from Thummelagudam, came to the OPD at 7.30 am with chief complaints of vomiting and loose stools since 3 am the previous night.


HISTORY OF PRESENTING ILLNESS:


Patient was apparently asymptomatic few hours back when she developed vomiting- 20 episodes, sudden in onset, non bilious, non projectile, with mainly water as content.

It was associated with burning type of pain abdomen involving all the quadrants.

Also associated with loose stools- 6 episodes, watery in consistency, not associated with blood or mucus.

No h/o fever and intake of food from outside, decreased urine output.


Past History:


History of similar complaints 1 year back.


Not a known case of Diabetes melitus, hypertension, TB, Asthma, CAD, Epilepsy.


Surgical History: 2 previous LSCS


General Examination:


Patient is conscious, coherent, co-operative.

Moderately built, moderately nourished.

Pallor - present

Icterus- absent 

Cyanosis- absent 

Clubbing- absent 

Koilonychia- absent 

Lymphadenopathy- absent 

Edema- absent 


Vitals:


Temperature- afebrile 

Pulse Rate- 96 beats/ min

Blood Pressure- 100/70 mm hug

Respiratory Rate- 18 cycles/ min

Spo2- 99%


GASTROINTESTINAL SYSTEM:

 


ORAL CAVITY


Lips: dry

Teeth: normal 

Gums: normal 

Tongue: dry 

Tonsils: normal 





PER ABDOMEN


Inspection:


  • Shape- scaphoid
  • Umbilicus- central and inverted 
  • Movements- in accordance with respiration 
  • No visible pulsation
  • No scars, sinuses, engorged veins 


Palpation:

  • Mild tenderness in all quadrants of abdomen 
  • No organomegaly 


Percussion:

  • Tympanic 
  • Liver dullness elicited in 5th intercostal space.

Auscultation:

  • Bowel sounds- present 


Investigations:

  1. Complete blood picture 

  2. Complete urine examination
  3. GRBS- 102 mg/dl
  4. Chest X-Ray
  5. Liver function Test6.Renal function Test


    6. Provisional Diagnosis:


    Acute Gastroenteritis 



    Treatment:


    • IV fluids-NS,RL,DNS-150 ml/hr
    • Inj pantop 40 mg IV/ OD
    • Inj zofer 2 cc IV TID
    • Inj metrogyl 100 ml IV TID- day 1 and day 3
    • Vitals monitoring 4 hourly 
    • GRBS 6 hourly 
    • Inj monocef 1 gm IV BD- day 1
    • TAB doxycycline 100 mg 3 tablets stat
    • TAB sporolac DS/ PO/BD
    • ORS sachets - 2 in 1 L water, 200 ml after each episode.

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