1601006095 LONG CASE

 

1601006095 GENERAL MEDICINE - LONG CASE

MEDICAL CASE DISCUSSION 

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..

     A 25 year old female patient tailor by occupation resident of Thummalagudem came to OPD at early morning 7.30 with chief complains of vomiting and loose stools since 3.00am in the morning

History of presenting illness-
Patient was apparently asymptomatic few hours ago then she developed 
VOMITINGS- sudden in onset, 
15 episodes,  non projectile,non bilious, and water as main content 
Vomitings are associated with burning type of pain involving all quadrants of abdomen.
LOOSE STOOLS- 7 episodes , watery in consistency, no foul smelling,  no mucus or blood in stools, no tenesmus
No h/o hematemesis
No h/o melena
No h/o fever
No h/o intake of food from outside 
No h/o decreased urine output 
No travel history.
Past history-
History of similar complain in the past 
Admitted in hospital for 1 day 
Not a known case of Diabetes mellitus,hypertension, Tuberculosis, asthma,epilepsy, thyroid.
Past surgical history- She has undergone 2 LSCS previously.
Personal history-
Mixed diet 
Normal appetite 
Adequate sleep 
Regular bladder and bowel movements 
No addictions
Family history-
Not significant 
No other member of family has similar complains.

General Examination-
Patient was conscious, coherent, co- operative. Well oriented to time, place and person.
Moderately built and moderately nourished .
No pallor
No icterus
No clubbing
No cyanosis
No lymphadenopathy 
No edema
VITALS-
Temperature- afebrile 
Pulse- 96bpm
Blood pressure- 100/70 mm of hg
Respiratory rate-18 cycles per minute 
SpO2-99%

Gastro-intestinal Examination-
Oral cavity-
Dry lips
Teeth- normal 
Gums- normal
Tongue -dry 
Tonsils- normal
PER ABDOMINAL EXAMINATION-
INSPECTION-
Shape- Scaphoid 
Umbilicus- central and inverted
Movements with respiration- equal in all quadrants, rises with inspiration and falls during expiration 
No visible pulsations 
No visible scars or sinuses seen 
No engorged veins 
Multiple stretch marks are seen 

PALPATION-
No local rise of temperature 
Mild tenderness present in all quadrants of abdomen
Liver and spleen- impalpable( no organomegaly)
PERCUSSION-
Tympanic note 
AUSCULTATION-
Bowel sounds present

Other systems-
CVS EXAMINATION-
S1, S2 heard
No murmurs
Apical impulse at 5th intercoastal space lateral to mid clavicular line
RESPIRATORY SYSTEM EXAMINATION- 
Trachea-midline
Bilateral air entry present 
Normal vesicular breath sounds heard
No additional sounds
CNS EXAMINATION-
Gait -normal
Sensations - present
Cranial nerves- intact
Reflexes preserved

Investigations-
CBP
GRBS
LFT
RFT
Chest X Ray
ECG
Other investigations to be done-
Stool examination and culture 
Sigmoidoscopy/ colonoscopy
Ultrasound abdomen 
Urine analysis 

Probable diagnosis- ACUTE GASTROENTERITIS 
 TREATMENT-
IV fluids-Normal saline 
Ringer lactate- 150ml/hr
Inj.Zofer- 2cc IV TID
Inj.Pantop- 40mg IV
Monitor vitals and check for signs of dehydration 
Inj. Metrogyl 100 ml IV TID
Inj.Monocef- 1g BD 
Tab.Doxycycline- 100mg ( 3 tablets)
Tab. Sporolac 
ORS - 2 sachets in 1 lt water , 200ml after each episode 




DIFFERENTIAL DIAGNOSIS- 
Food poisoning 
Inflammatory Bowel Disease
Malabsorption 

Comments

Post a Comment

Popular posts from this blog

  2K16 BATCH UNIVERSITY PRACTICAL EXAMS    DEPARTMENT OF GENERAL MEDICINE   DATE: 26.04.2021 (MONDAY) S. NO HALLTICKET NO CASE BLOG LINKS  CASE PRESENTATION VIDEO LINKS      1 1601006001 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-long-case-april-23-2021-hall.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-short-case-april-25-2021.html https://youtu.be/9xE26ZkzqDg 2 1601006002 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-long-case.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-short-case.html https://youtu.be/7jBj-Fz8kc4 3 1601006003 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006003-long-case-50-
Read more

1601006161 SHORT CASE

Image
  SHORT CASE : A 34-YEAR-OLD GENTLEMAN WITH CHRONIC KIDNEY DISEASE UNDERGOING DIALYSIS   HALL TICKET NUMBER : 1601006161 A 34-year-old gentleman, from Motukur, who is a labourer by occupation, came to the hospital on 17/04/2021, for Maintenance Hemodialysis. History of presenting illness : The patient was apparently asymptomatic 3 years ago, when he was diagnosed with  Hypertension, secondary to Chronic Kidney Disease.  He was regularly taking his medication for Hypertension, until he  abruptly stopped  doing so 2 months ago. The patient has been  undergoing maintenance hemodialysis at our hospital since the past 10 months . He complains of facial puffiness, abdominal distension and swelling in the legs.  The patient also complains of loss of weight over the past 3 years. Initially, he was 63 kg, now he is 52 kg. General Physical Examination : The patient is conscious, coherent and cooperative, lying supine on the bed He is well oriented to time, place and person. He is moderately buil
Read more

1601006107 LONG CASE

Image
  LONG CASE : A 50-YEAR-OLD LADY WITH LEFT-SIDED WEAKNESS OF THE BODY AND DEVIATION OF THE MOUTH TOWARDS THE RIGHT A 50-year-old lady, from Suryapet, who is a homemaker, came to the hospital on 20/04/2021 at 3 PM, and was examined on 24/04/2021 at 10 AM, with Chief Complaint s  of : 1) W eakness of the left upper and lower limbs since 5 days 2) Deviation of the angle of mouth towards the right since 5 days 3) Slurred speech since 5 days. History of Presenting illness  :  The patient was apparently asymptomatic  5 days ago , when  at around 9 AM in the morning, on 20/04/2021 : She felt a sudden  weakness of her left upper and lower limbs. The episode was  sudden in onset, initially began as a slight weakness of the left upper limb, which progressively worsened with time and the evolution of weakness had completed within 6 hours ,  with a complete inability to move both - her left upper and lower limbs ,   following which she was brought to the hospital by her family members, at around 
Read more