1601006146 SHORT CASE

 

GENERAL MEDICINE FINAL PRACTICAL 

"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-centered online learning portfolio and your valuable inputs on the comment.

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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