1601006073 SHORT CASE

 

A case of 62 year old female with Gastrointestinal disturbances




"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 reflects my patient-centered online learning portfolio and your inputs on the comment box is welcomed.

Short case,
1601006073,

This is an online E log book to discuss our patients deidentified health data shared after taking her/ guardians  signed informed consent.

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

 • Fever since 5 days

. Pain abdomen since 4 day's

. Vomitings

. Loose motions since 4 day's

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.

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

                PR-72 bpm

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

Auscultation:

Bowel sounds normal.

Respiratory system:

Bilateral air entry present

Vesicular breath sounds heard , no added sounds.

CVS:

S1 & S2 heard , no murmurs

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

CNS:

Patient is concious, speech  normal , cranial nerves intact.

Investigations:

1.CBP:


2.blood grouping:


3.CUE:


4.RFT:


5.LFT:


6.fasting blood sugar.


7.urine protein/creatinine ratio.

8.chest x-ray.




Treatment given:

Injections:

1.tramadol


2.ondansetron

Cefixime:400 mg po sd.

4.Plenty of fluids and right diet.


Differential Diagnosis:

1.inflammatory bowel syndrome.

2.Malabsorption.

3.Diabetic ketoacidosis.

4.food poisoning.

Provisional Diagnosis:

-Acute gastroenteritis.

Prevention:

1.washing hands thoroughly with soap and water.

2.using disposable paper towels.

3.proper food storage.

Prognosis: fair

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