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

ABG

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