1601006180 LONG CASE

 

1601006180



This is 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome     

LONG CASE FOR PRACTICAL EXAM:

A 25year old female patient,tailor by occupation, hailing from thummalagudam,came to OPD at 7:30 am with chief complaints of vomitings and loose stools since 3am the previous night.

History Of Presenting Illness:

patient was apparently asymptomatic few hours back then she developed vomitings:30 episodes, sudden in onset,non-bilious,non-projectile,initially food later water as content.It was associated with burning type of pain in epigastric region.

Also associated with loose stools:6 episodes, watery in consistency, not associated with blood or mucus,no foul smell.

H/o burning micturition since 3 days.

No h/o fever,no h/o intake of food from outside.

No h/o decreased urine output. No h/o hematemesis,malena

PAST HISTORY 

H/o similar complaints 1yr back

Admitted in hospital for 2 days,pantop and NS are given and discharged. 

Not a known case of diabetes, hypertension, tuberculosis, asthma, epilepsy. Surgical history:2 LSCS

PERSONAL HISTORY 

Diet:mixed(prefers fast food,spicy food),habit of eating late nights.

Appetite:normal

Sleep:adequate 

Bladder&Bowel movements:regular

Addictions:no addictions

FAMILY HISTORY 

Not significant 

DRUG HISTORY 

used pantop for 2 days due to previous similar complaint. 

GENERAL EXAMINATION 

Patient is conscious, coherent, co operative. Moderately built and nourished. Well oriented to time,place,person. 

Pallor:absent

Icterus:absent
Cyanosis:absent
Clubbing:absent 
Lymphadenopathy:absent
Edema:absent  

VITALS: temperature:Afebrile
Pulse:96bpm
BP: 100/70 mm of Hg
RR:18cpm
Sp02:99%
GASTRO INTESTINAL SYSTEM:
oral cavity: lips-dry,tongue-dry,teeth-normal,gums-normal,tongue-normal,tonsils-normal.
PER ABDOMEN:
Inspection:shape-scaphoid
Umbilicus-central
Movements-in accordance with respiration. 
Multiple stretch marks 
No visible pulsations,
LSCS scar
No sinuses, engorged veins
Palpation: no local rise of temperature 
mild tenderness in all quadrants of abdomen.
No organomegaly.
Percussion:tympanic note.
Auscultation:bowel sounds heard.
CVS: S1,S2 heard,no murmurs
RESPIRATORY SYSTEM: Bilateral air entry,normal vesicular breath sounds,trachea -midline
CNS:gait-normal,sensations-normal,cranial nerves-normal,reflexes-preserved.
INSVESTIGATIONS: CBP 
 GRBS 

 LFT

RFT 
 XRAY 
ECG 
 PROVISIONAL DIAGNOSIS: Acute gastroenteritis. 
TREATMENT:IV fluids
ringer lactate,-150ml/hr
Inj pantop-40mg IV
Inj-zofer 2ccIV TID
Inj-metrogyl 100ml IV TID Day 1 and Day3.
Vitals monitoring- 4hrly,GRBS-6hrly.
Inj-monocef-1gm IV BD:Day 1
Tab doxycycline 100mg -3tab
Tab sporolac 
ORS sachets-2 in 1L water,200ml after each episode.
 
 
Differential Diagnosis:food poisoning, Inflammatory bowel syndrome,Malabsorption. 

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