Short case for practical exam

 A 25 year old female patient , tailor by occupation, hailing from Thummelagudam, came to the OPD at 7.30 am with chief complaints of vomiting and loose stools since 3 am the previous night.


HISTORY OF PRESENT ILLNESS:


Patient was apparently asymptomatic few hours back when she developed vomiting- 20 episodes, sudden in onset, non bilious, non projectile, with mainly water as content.

It was associated with burning type of pain abdomen involving all the quadrants.

Also associated with loose stools- 6 episodes, watery in consistency, not associated with blood or mucus.

H/o burning micturition since 3 days.

No h/o fever and intake of food from outside, decreased urine output.


Past History:


History of similar complaints 1 year back.

History of Urinary tract infection- 3 episodes in the last 8 years.


Not a known case of Diabetes melitus, hypertension, TB, Asthma, Epilepsy.


Surgical History: 2 previous LSCS


General Examination:


Patient is conscious, coherent, co-operative.

Moderately built, moderately nourished.

Pallor - present

Icterus- absent 

Cyanosis- absent 

Clubbing- absent 

Koilonychia- absent 

Lymphadenopathy- absent 

Edema- absent 


Vitals:


Temperature- afebrile 

Pulse Rate- 96 beats/ min

Blood Pressure- 100/70 mm hug

Respiratory Rate- 18 cycles/ min

Spo2- 99%


GASTROINTESTINAL SYSTEM:

 


ORAL CAVITY


Lips: dry

Teeth: normal 

Gums: normal 

Tongue: dry 

Tonsils: normal 





PER ABDOMEN


Inspection:


  • Shape- scaphoid
  • Umbilicus- central and inverted 
  • Movements- in accordance with respiration 
  • No visible pulsation
  • No scars, sinuses, engorged veins 


Palpation:

  • Mild tenderness in all quadrants of abdomen 
  • No organomegaly 


Percussion:

  • Tympanic
  • Liver dullness elicited in 5th intercostal space.

Auscultation:

  • Bowel sounds- present 


Investigations:

  1. Complete blood picture 

  2. Complete urine examination
  3. GRBS- 102 mg/dl
  4. Chest X-Ray
  5. Liver function Test6.Renal function Test


Provisional Diagnosis:


Acute Gastroenteritis 



Treatment:


  • IV fluids-NS,RL,DNS-150 ml/hr
  • Inj pantop 40 mg IV/ OD
  • Inj zofer 2 cc IV TID
  • Inj metrogyl 100 ml IV TID- day 1 and day 3
  • Vitals monitoring 4 hourly 
  • GRBS 6 hourly 
  • Inj monocef 1 gm IV BD- day 1
  • TAB doxycycline 100 mg 3 tablets stat
  • TAB sporolac DS/ PO/BD
  • ORS sachets - 2 in 1 L water, 200 ml after each episode.

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