1601006146 SHORT CASE

 

GENERAL MEDICINE FINAL PRACTICAL 

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SHORT CASE


A 25 year old female patient , Tailor by occupation, resident of Thummelagudam [Nalgonda Dist], came to the OPD at with chief complaints of vomiting and loose stools since 3 am the previous night.


History of presenting illness:


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 pain abdomen burning type, in all over the abdomen.Also associated with loose stools- 6 episodes, watery in consistency, not associated with blood or mucus.


H/o Burning micturition since 3 days.


No H/o fever and intake of food from outside, decreased urine output.


Past History:


  • History of similar complaints 1 year back.
  • History of Urinary tract infection- 3 episodes in the last 8 years.
  • Not a known case of DM, HTN, 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 hug
  • Respiratory Rate- 18 cycles/ min
  • SpO2- 99%



SYSTEMIC EXAMINATION


GIT Examination


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 veins




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






Provisional Diagnosis:  Acute Gastroenteritis.



Treatment:


  • IV fluids-RL,DNS-150 ml/hr
  • Inj. Pantop 40 mg IV/ OD
  • Inj. Zofer 2 ml IV TID
  • Inj. Metrogyl 100 ml IV TID
  • Inj. Monocef 1 gm IV BD
  • TAB Doxycycline 100 mg 3 tablets stat
  • TAB Sporolac PO/BD
  • ORS Sachets - 2 in 1 L water, 200 ml after each episode.

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