1601006191 LONG CASE

 1601006191

This is an online e log book ,which discusses our patients health data, collected after a signed informed consent.


A 65 yr old female, resident of narketpally,a house wife ,came to hospital with the

Chief complaints of fever with chills since 8 days.Pain abdomen and loose stools since 6 days.


History of presenting illness:

The patient was apparently asymptomatic 8 days back. 


Then she developed-

-Fever, which was sudden in onset,low grade,associated with chills and rigors and relieved on medication.

-Pain in lower abdomen 6 days ago, sudden in onset continuous, cramping/dull aching type, aggravates with food intake.

-Associated with vomiting 2-3episodes/day, non bilious non projectile watery consistency.


-Loose stools 6 days back multiple episodes in large volume watery, no tenesmus, no mucous or blood in stools.


-History of burning micturition since 4 days, no froth/blood.

-No hematemesis/malena.


Past history:

-History of diabetes type2 since 10years

-History of hypertension since 10years

-No history of Tuberculosis , asthma, epilepsy ,thyroid disorders, CAD, stroke.


Drug history:

-Diabetes -metformin 500mg+idalgliptin 500mg

-Hypertension - telmisartan-40mg





Personal history 

-Diet mixed.

-Sleep disturbed due to loose stools.

-Appetite decreased.

-Bowel- irregular 

-Bladder- urge incontinenece

-No known allergies

-No alcohol 

-No smoking 


Family history:

 -Not significant 


General examination:

-Patient is conscious,  coherent and cooperative.

Well oriented to time place and person. Moderately built & Well nourished 

-Pallor : present

-No Icterus ,Koilonychia ,Clubbing ,Lymphadenopathy ,Edema.


Vitals

-Temperature afebrile

-Bp: 110/80 mm hg

-Pulse 90bpm

-Respiratory rate 19/min

-Spo2 96%


Systemic examination:

Per Abdominal examination 

 Inspection:

-Generalised distention/fullness is seen.

-Shape- distended 

-Flanks full

-Umbilical inverted

-Movements with respiration-  equal in all quadrants. Rises during inspiration falls during expiration.

-No visible pulsations.

-Skin over abdomen multiple vertical stretch marks, horizontal scars.





Palpation :

-No local rise of temperature. 

-Tenderness - diffuse.

-Liver,Gall bladder,Spleen impalpable.

Percussion:

-Shifting dullness- not present

-Fluid thrill not present

Auscultation 

-Bowel sound normal 

Other system examination

CVS

-S1 , S2 heard

-Apical impulse 5th intercostal space  lateral to midclavicular line.

-No murmers

Respiratory system

-Bilateral air entry

-Normal vesicular breathsounds

-Bronchial breath sounds heard

-Trachea midline 

CNS      

-Gait normal 

-Sensations normal 

-Cranial nerve normal

-Reflexes preserved


INVESTIGATIONS:

Stool examination & culture
Sigmoidoscopy/colonoscopy 
Ultrasound abdomen and xray are rarely suggested. 
Urine analysis 
Renal funtion tests

Urine examination:
Increased  pus cells in urine

Hemogram 

Renal function tests 

Fasting blood sugar
Urine protien/creatinine ratio
Complete urine examination
Glycated hemoglobin
ECG 

Possible Diagnosis:
Acute gastroenteritis.

Injections


Antibiotic cephalosporins- cefixime


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