A case of 62 year old female with Gastrointestinal disturbances,short case

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Short case,

1601006073,

This is an online E log book to discuss our patients deidentified health data shared after taking her/ guardians  signed informed consent.

A 65 year old female,homemaker, resident of narketpally, came to the hospital with the chief complaints of:-

 • Fever since 5 days

. Pain abdomen since 4 day's

. Vomitings

. Loose motions since 4 day's

History of present illness:

Patient was apparently asymptotic 5 days back , then she developed fever  which was 

- sudden in onset

- low grade

- associated with chills and rigor

- which is relieved by medication.

Pain abdomen:

Pain in the right lower quadrant of abdomen which is cramp like dull ache in nature

Which was sudden in onset

Relieved by taking medication

Vomitings:

- 3 episodes / day

- nonprojectile , content - has food particles

- non bilious.

Loose stools:

3 to 4 times a day,subsided with medication.

General examination:

Patient is concious , coherent , co operative ,moderately build moderately nourished

Pallor  present

No icterus, no clubbing, no koilonychia, lymphadenopathy, edema..

Vitals:

              temp - a febrile

             B.P- 110/80 mmHg

               RR -18 CPM

                PR-72 bpm

Per abdominal examination.

Inspection:fullness/generalized distension.

Skin over abdomen normal

                   No scars , sinuses , engorged                         veins

                   No visible pulsations,

                     Umblicus - normal

Palpation:

no local rise of temperature

    No tenderness, no rigidity, no guarding

      No organomegaly

   ( liver, spleen , kidney - not palpable ).

Percussion:

tympanic note heard  all over abdomen, shifting dullness  & fluid thrill absent

Auscultation:

Bowel sounds normal.

Respiratory system:

Bilateral air entry present

Vesicular breath sounds heard , no added sounds.

CVS:

S1 & S2 heard , no murmurs

Apex beat : left 5 th intercoastal space in the medial to mid clavicular line.

CNS:

Patient is concious, speech  normal , cranial nerves intact.

Investigations:

1.CBP:

2.blood grouping:

3.CUE:

4.RFT:

5.LFT:

6.fasting blood sugar.

7.urine protein/creatinine ratio.

8.chest x-ray.

Treatment given:

Injections:

1.tramadol

2.ondansetron

Cefixime:400 mg po sd.

4.Plenty of fluids and right diet.

Differential Diagnosis:

1.inflammatory bowel syndrome.

2.Malabsorption.

3.Diabetic ketoacidosis.

4.food poisoning.

Provisional Diagnosis:

-Acute gastroenteritis.

Prevention:

1.washing hands thoroughly with soap and water.

2.using disposable paper towels.

3.proper food storage.

Prognosis: fair