1601006079 LONG CASE

 

1601006079



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. 

65 year old female with fever , generalised abdominal pain and loose stools.


A 65 yr old woman, from narketpally who is a house wife ,came to the hospital with chief complaints of fever with chills since 8 days and pain abdomen since 6 days, vomiting and loose stools since 6 days.


*HISTORY OF PRESENT ILLNESS-


The patient was apparently  asymptomatic one week back and then she developed Fever-which was sudden in onset, high grade, associated with chills and rigor, relieved on medication


Lower abdominal pain-sudden in onset,continuous cramping like/dull aching and aggravated on food intake

Vomiting-2-3 episodes /day,non-bilious,non-projectile,watery consistency

Loose stools-multiple episodes in large volume, watery,non blood or mucous in stools

History of burning micturition since 4 days-high coloured urine and no hematuria

*PAST HISTORY-

History of diabetes type 2 since 10 years and on medication

History of hypertension since 10 years and on medication

No history of epilepsy ,asthma, seizures

*TREATMENT HISTORY-

Diabetes-metformin 500 mg+idalgliptin 500 mg

Hypertension-telmisartan-40 mg

*PERSONAL HISTORY-

Diet-mixed

Appetite-decreased

Bowel movements-irregular

Bladder-incontinence with burning micturition

No known allergies

No addictions

*FAMILY HISTORY-not significant

*GENERAL EXAMINATION-

Patient is conscious,coherent and cooperative.

Well oriented to time,place and person,moderately built and moderately nourished

Pallor-present

Icterus-absent

Clubbing-absent

Cyanosis-absent

Koilonychia-absent

Lymphadenopathy-absent

Edema-facial puffiness present

VITALS-

Temperature-98.5 F,afebrile

Blood pressure-120/90mm Hg

Pulse-110/min

RR-26cpm

SpO2-96% at room air

*SYSTEMIC EXAMINATION-

*ABDOMEN-

Inspection-

Shape-distended,flanks full







Umbilicus-inverted

Movements with respiration -equal in all quadrants

Skin over abdomen-multiple vertical and horizontal striae present


Palpation-

Tenderness-diffuse in right iliac fossa

Liver impalpable

Gall bladder impalpable

Spleen impalpable


Percussion-

Shifting dullness not present

Fluid thrill not present


Auscultation-

Bowel sounds heard


OTHER SYSTEM EXAMINATION-


CVS-S1,S2 heard

Apical impulse - normal 

No murmurs

RESPIRATORY SYSTEM-

Normal vesicular breath sounds heard

Bronchial breath sounds heard

Trachea midline


CNS-

Cranial nerve examination:normal

Gait:normal 

Reflexes:normal


CHEST XRAY


HEMOGRAM-



  RENAL FUNCTION TEST-




    COMPLETE URINE EXAMINATION-


     FASTING BLOOD SUGAR-


USG REPORT-



   Hb1Ac-







INVESTIGATIONS-


Stool examination and culture

Sigmoidoscopy/colonoscopy

Urine analysis


RENAL FUNCTION TESTS-

Increased serum creatinine levels

Decreased leucocytes



URINE EXAMINATION-

Increased pus cells in urine


PROVISIONAL DIAGNOSIS-

Acute gastroenteritis

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