1601006092 short case

 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.

HOPI:

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 quarters.

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, CAD, 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:

• Tympapic
• 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.