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.

Comments

Post a Comment

Popular posts from this blog

  2K16 BATCH UNIVERSITY PRACTICAL EXAMS    DEPARTMENT OF GENERAL MEDICINE   DATE: 26.04.2021 (MONDAY) S. NO HALLTICKET NO CASE BLOG LINKS  CASE PRESENTATION VIDEO LINKS      1 1601006001 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-long-case-april-23-2021-hall.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-short-case-april-25-2021.html https://youtu.be/9xE26ZkzqDg 2 1601006002 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-long-case.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-short-case.html https://youtu.be/7jBj-Fz8kc4 3 1601006003 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006003-long-case-50-
Read more

1601006161 SHORT CASE

Image
  SHORT CASE : A 34-YEAR-OLD GENTLEMAN WITH CHRONIC KIDNEY DISEASE UNDERGOING DIALYSIS   HALL TICKET NUMBER : 1601006161 A 34-year-old gentleman, from Motukur, who is a labourer by occupation, came to the hospital on 17/04/2021, for Maintenance Hemodialysis. History of presenting illness : The patient was apparently asymptomatic 3 years ago, when he was diagnosed with  Hypertension, secondary to Chronic Kidney Disease.  He was regularly taking his medication for Hypertension, until he  abruptly stopped  doing so 2 months ago. The patient has been  undergoing maintenance hemodialysis at our hospital since the past 10 months . He complains of facial puffiness, abdominal distension and swelling in the legs.  The patient also complains of loss of weight over the past 3 years. Initially, he was 63 kg, now he is 52 kg. General Physical Examination : The patient is conscious, coherent and cooperative, lying supine on the bed He is well oriented to time, place and person. He is moderately buil
Read more

1601006107 LONG CASE

Image
  LONG CASE : A 50-YEAR-OLD LADY WITH LEFT-SIDED WEAKNESS OF THE BODY AND DEVIATION OF THE MOUTH TOWARDS THE RIGHT A 50-year-old lady, from Suryapet, who is a homemaker, came to the hospital on 20/04/2021 at 3 PM, and was examined on 24/04/2021 at 10 AM, with Chief Complaint s  of : 1) W eakness of the left upper and lower limbs since 5 days 2) Deviation of the angle of mouth towards the right since 5 days 3) Slurred speech since 5 days. History of Presenting illness  :  The patient was apparently asymptomatic  5 days ago , when  at around 9 AM in the morning, on 20/04/2021 : She felt a sudden  weakness of her left upper and lower limbs. The episode was  sudden in onset, initially began as a slight weakness of the left upper limb, which progressively worsened with time and the evolution of weakness had completed within 6 hours ,  with a complete inability to move both - her left upper and lower limbs ,   following which she was brought to the hospital by her family members, at around 
Read more