1601006067 SHORT CASE

 

1601006067 - Final Year Practical 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 - centred online learning portfolio and your valuable inputs in the comments.


 A 25 year old female tailor by occupation from Thummelagudam came to OPD with chief complaints of

1. Vomiting

2. Loose stools since morning

History of presenting illness :

- She was apparently asymptomatic few hours back then she developed vomiting 

- It was sudden in onset , non bilious , non projectile , 20 episodes , mainly water as content

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

- Loose stools of 6 episodes , watery in consistency , not associated with blood or mucus 

- No h/o fever

- No h/o intake of food from outside

Past History :

- History of similar complaints 1 year back
- Not a known case of Diabetes , HTN , TB , Asthma , Epilespsy
- H/o of 2 previous LSCS 

General Examination :

- Consent was obtained
- She was Conscious , Coherent , Cooperative , Moderately built & nourished 
- Pallor present 
- No Cyanosis , Clubbing , Lymphadenopathy , Edema

VITALS :

Temperature - Afebrile
Pulse Rate - 96 bpm
Blood Pressure - 100/70 mmHg
Respiratory Rate - 18 cpm

GastroIntestinal System :

ORAL CAVITY :

1. Lips - Dry
2. Teeth - Normal
3. Gums - Normal
4. Tongue - Dry
5. Tonsils - Normal



PER ABDOMEN :

INSPECTION -

1. Shape - Scaphoid
2. Umbilicus - Central & inverted
3. Movements in accordance with respiration 
4. No visible pulsation
5. No scars , sinuses , engorged veins



PALPATION -

1. Mild tenderness in all quadrants of abdomen
2. No organomegaly

PERCUSSION -

1. Tympanic note
2. Liver dullness elicited at 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 test
6. Renal function test

Provisional Diagnosis :

Acute Gastroenteritis 

Treatment :

1. IV Fluids - NS , RL , DNS 150 ml/hr
2. Inj. Pantop 40 mg OD
3. Inj. Zofer 2 cc TID
4. Inj. Metrogyl 100 mg TID on day 1 & 3
5. Vitals monitored 4 hrly
6. GRBS 6 hrly
7. Inj. Monocled 1 gm BD on day 1
8. Tab. Doxycycline 100 mg TID
9. Tab. Sporolac DS/PO/BD
10. ORS sachets - 2 in 1 L water , 200 ml after each episode

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