1601006063 SHORT CASE

 

1601006063 Short case

This is an online E log to discuss our patient's 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 also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

       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.

HOPI:
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, burning micturition 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 hg
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 
Palpation:
Mild tenderness in all quadrants of abdomen 
No organomegaly 
Percussion:
Tympanic
Liver dullness elicited in 5th intercostal space.
Auscultation:
Bowel sounds- present 

Investigations:

Complete blood picture 
Complete urine examination
GRBS- 102 mg/dl
Chest X-Ray
Liver function Test
Renal function test

Probable 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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