1601006095 LONG CASE

 

1601006095 GENERAL MEDICINE - LONG CASE

MEDICAL CASE DISCUSSION 

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     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 

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