Hi, I am princy rose , 5 th sem medical student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.
June 8,2023
Case scenario......
CASE SHEET:
A 50 yr old woman who is a housewife , resident of narketpally , came to the OPD with cheif complaints of loose motions and vomitings
Date of admission: 05-06-2023
CHEIF COMPLAINTS:
Loose stools (watery) : 5-10 episodes since one day .
1 episode of vomitting.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 5 days ago . Then she developed loose motions . She had 10 episodes of loose stools which were watery , non bilious , in small quantity.
She had no c/o abdominal pain .
She also had an episode of vomitting the same night . It was watery , non bilious, contained food particles , non projectile.
She developed high fever the same night , which was relieved on taking Tab. Dolo 650 mg .
No c/o SOB , chest pain , palpitations, headache, dizziness .
HISTORY OF PAST ILLNESS
She has h/o Acute CVA (rt upper and lower hemoparesis ) 4 months ago , for which she was given Inj. Tenecteplase/stat dose and recovered within a day .
k/c/o diabetes mellitus since 17 yrs .
k/c/o hypertension since 1 yr.
Surgical history: Patient is tubectomised
DRUG HISTORY :
1) Tab. Telmisartan 40mg PO /OD for Hypertension for past 1yr.
2)Tab. Metformin 500mg PO/OD for diabetes since last 17 yrs .
PERSONAL HISTORY
Occupation: Housewife
Patient is married .
Patient is vegetarian (since 3 yrs) and has a normal appetite .
Sleep : Regular
Bladder movements are normal , bowel movements increased
No known allergies .
Addictions : Occasional alcoholic, stopped since 1 yr .
FAMILY HISTORY
Not significant
GENERAL EXAMINATION
Pallor : seen
Icterus : not seen
Cyanosis : not seen
Clubbing : not seen
Lymphadenopathy : not seen
Edema : Not seen
VITALS :
Afebrile
PR : 82 beats per minute
BP : 120/80 mm of Hg
RR : 16 cycles per minute
SpO2 : 97% in room air
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM EXAMINATION:
s1 and s2 heard
Thrills absent.,
No cardiac murmurs
RESPIRATORY SYSTEM:
Normal vesicular breath sounds heard.
Bilateral air entry present
Trachea is in midline.
ABDOMINAL EXAMINATION:
INSPECTION:
Shape - Scaphoid
Equal movements in all the quadrants.
No visible pulsation, dilated veins and localized swellings.
PALPATION:
Liver , spleen not palpable.
No tenderness
CENTRAL NERVOUS SYSTEM EXAMINATION:
Conscious and coherent
Speech : Normal
No signs of meningeal irritation
Cranial Nerves - intact
PROVISIONAL DIAGNOSIS: ACUTE GASTROENTERITIS .
INVESTIGATIONS :
1) USG
2) ECG
3)RPR
4) ANTI - HCV Abs
5) HBsAg
6) HEMOGRAM
7
) COMPLETE URINE EXAMINATION
8)BLOOD GROUPING AND RH TYPE
9) GRBS
10) BLOOD UREA
11) GLYCATED HAEMOGLOBIN
12) SERUM CREATININE
13) SERUM ELECTROLYTES
14) LFT
TREATMENT
1) IV Fluids NS at 75 ml/hr .
2) Inj. Metrogyl 500ml/IV/TID.
3) Tab. Sporolac DS - 2tabs PO/BD
4) ORS in 1L water 200ml after every episode of loose stool.
5) Monitoring vitals .
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