1601006155 SHORT CASE

 

1601006155- Short Case


GENERAL MEDICINE E LOG BOOK

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SHORT CASE FOR PRACTICAL EXAMINATION 


A 25 year old female patient , tailor by occupation, hailing from Thummelagudam, came to the OPD at 7.30 am with chief complaints of vomiting and loose stools since 3 am the previous night.


HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic few hours back when she developed vomiting- 20 episodes, sudden in onset, non bilious, non projectile, with water as content.

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

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 Diabetes melitus, hypertension, 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 mmHg

Respiratory Rate- 18 cycles/ min

Spo2- 99%


GASTROINTESTINAL SYSTEM:

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 pulsations

        •      No scars, sinuses, engorged veins 





Palpation:

• Mild tenderness in all quadrants of abdomen 

• No organomegaly 


Percussion:

• Tympapic

• Liver dullness elicited in 5th intercostal space.

Auscultation:

• Bowel sounds- present 


INVESTIGATIONS: 

  1. 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-NS,RL,DNS-150 ml/hr

• Inj pantop 40 mg IV/ OD

• Inj zofer 2 cc IV TID

• Inj metrogyl 100 ml IV TID- day 1 and day 3

• Vitals monitoring 4 hourly 

• GRBS 6 hourly 

• Inj monocef 1 gm IV BD- day 1

• TAB doxycycline 100 mg 3 tablets stat

• TAB sporolac DS/ PO/BD

• ORS sachets - 2 in 1 L water, 200 ml after each episode.

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