1601006060 SHORT CASE

 

HALL TICKET NO: 1601006060 SHORT CASE.



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A 65 year old female, homemaker, resident of narketpally, came to the hospital with the chief complaints of:-
  
Complaints:-

. Fever since 5 days

. Pain abdomen since 4 days.

.  Vomitings since 4days.

. Loose motions since 4 days.

History of present illness:-

Patient was apparently asymptotic 5 days back , then she developed  Fever which was

- sudden in onset

- low grade

- associated with chills and rigor

- which is relieved by medication.

Pain abdomen :

Pain in the right lower quadrant of abdomen which is cramp like dull ache in nature

Which was sudden in onset

Relieved by taking medication

Vomitings :

- 3 episodes / day

- nonprojectile , content - has food particles

- non bilious

Loose stools :

3 to 4 times a day, subsided with medication , 

Past history :

She is a known case of DM , HTN ,since 8 years

She is on medication for that

Not a known case of asthma, TB , Epilepsy,CAD, thyroid, stroke.

Family history :
no similar complaints in the past.

No history of asthma, TB,CAD, thyroid,stroke , diabetes , hypertension.

Personal history :

Diet - mixed

Appetite- normal

Sleep - disturbed due to abdominal pain

Bladder - regular

Addictions : toddy occasionally

General examination :

Patient is concious , coherent , co operative ,moderately build moderately nourished

Pallor present

No icterus, no clubbing, no koilonychia, lymphadenopathy, edema.

Vitals :
            temp - a febrile

             B.P- 110/80 mmHg

               RR -18 CPM

 
Per abdominal examination :

Inspection : fullness / generalized distension









      Skin over abdomen normal
        No scars , sinuses , engorged veins

         No visible pulsations,

          Umblicus - normal

     Palpation : 
   no local rise of temperature

    No tenderness, no rigidity, no guarding

      No organomegaly

   ( liver, spleen , kidney - not palpable )

Percussion : 
tympanic note heard all over abdomen, shifting dullness & fluid thrill absent

Ascultation :
bowel sounds normal

Respiratory system:

Bilateral air entry present

Vesicular breath sounds heard , no added sounds.

Cardio vascular system :

S1 & S2 heard , no murmurs

Apex beat : left 5 th intercoastal space in the medial to mid clavicular line.

Central nervous system :

Patient is conscious, speech normal , cranial nerves intact .

Differential diagnosis:-
     . Acute gastroenteritis
   . Food poisoning
  . Diabetic ketoacidosis

Provisional diagnosis:-
Acute gastroenteritis

Investigations :

. CBP

. Blood grouping

. CUE 

. RFT

. LFT

. Stool culture

. RBS













TREATMENT GIVEN:-











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