G.KRUPALATHA HALL TICKET NO: 1601006060 SHORT CASE.



"This is an online E log book to discuss our patient\"s de-identified health data shared after taking his/her/guardian\"s signed informed consent. Here we discuss our individual patient\"s problems through series of inputs from available global online community of experts with an aim to solve those patient\"s clinical problems with collective current best evidence based inputs. This E log book reflects my patient-centered online learning portfolio and your inputs on the comment box is welcomed

April 28, 2021


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

. Fever since 5 days

. Pain abdomen since 4 days.

.  Vomitings since 4days.

. Loose motions since 4 days.

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 , 

Past history :

She is a known case of DM , HTN ,since 8 years

She is on medication for that

Not a known case of asthma, TB , Epilepsy,CAD, thyroid, stroke.

Family history :
no similar complaints in the past.

No history of asthma, TB,CAD, thyroid,stroke , diabetes , hypertension.

Personal history :

Diet - mixed

Appetite- normal

Sleep - disturbed due to abdominal pain

Bladder - regular

Addictions : toddy occasionally

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

 
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

Ascultation :
bowel sounds normal

Respiratory system:

Bilateral air entry present

Vesicular breath sounds heard , no added sounds.

Cardio vascular system :

S1 & S2 heard , no murmurs

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

Central nervous system :

Patient is conscious, speech normal , cranial nerves intact .

Differential diagnosis:-
     . Acute gastroenteritis
   . Food poisoning
  . Diabetic ketoacidosis

Provisional diagnosis:-
Acute gastroenteritis

Investigations :

. CBP

. Blood grouping

. CUE 

. RFT

. LFT

. Stool culture

. RBS


CUE :
 RFT :
 LFT :
TREATMENT GIVEN:-











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