A 60yr old female with Loose stools and vomitings

(Short case ) Final examination
KNRUHS 
1701006180

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients  clinical problem with current best evidence based input.

This Elog also reflects my patient centered online learning portfolio.
I have been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment

Chief complaints::

60 yr old female labourer by occupation came with chief complaints of Loose stools since 15 days, vomitings since 10 days

History of present illness::

Loose stools since 15 days which was 8-10 episodes initially now since 4 days decreased to 4-5 episodes per day associated with abdominal pain in upper quadrant colicky in nature non radiating
Vomitings was of 2 episodes previously non bilious non projectile with food as content

Past history::

No history of similar complaints in past
H/o allergic reactions on both upper limbs
No history of diabetis mellitus, hypertension, asthma, Tuberculosis,CAD.

Personal history::

Diet :mixed
Appetite:normal
Sleep:Adequate
Bowel and bladder: normal
Addictions: occasionally toddy  

Surgical history:H/o hysterectomy 10 yrs back

General examination::

On taking prior consent patient was examined in a well lit room 

Patient was conscious coherent cooperative
Well oriented to time place person
Moderately nourished and  built

No pallor,icterus,cyanosis, kilonychia Lymphadenopathy,edema

Vitals::
Temperature: afebrile
Pulse:80bpm
Respiratory rate:16cpm
Bp:110/80mmof Hg

Systemic examination::

Per abdomen:::

Inspection..

Shape of abdomen...scaphoid
Umbilicus..inverted,central located
No sinuses or scars on abdomen

Palpation::

No rise in temperature
Tenderness present over upper quadrant  epigastric 
No palpable mass 
No free fluid
Liver palpable
Spleen not palpable

Percussion::

Dull note on right upper quadrant
No fluid thrill
No shifting dullness

Auscultation::

Bowel sound heard

Respiratory system::

B/L symmetrical elliptical
Trachea central
No sinuses ,scars

TVF..equal normal on both sides
Normal vesicular breath sounds heard

Cardio vascular system::
S1s2 heard
JVP not raised
No murmurs

Central nervous system::
Speech normal
Cranial nerves intact
Sensory and motor system: normal
Reflexes.normal

Investigations::

Complete blood picture::

Hemoglobin:12.2gm/dl
Total leucocyte count:5500cels/mm3
Neutrophils:70 %
Lymphocytes:20%
Monocytes:04%
Eosinophils:06%
Basophils:0
Platelet count:2L/mm3

Random blood sugar::102mg/dl

Blood urea 42mg/dl

Serum electrolytes::

Na+:::137
K+:::2.5
Cl-:::102

Serum creatinine::.  1.2mg/dl

Liver function tests::
 
Total bilirubin::0.91 mg/dl
Direct bilirubin::0.18 mg/dl
AST::41IU/L
ALT::43IU/L
ALP::154IU/L
Total protiens::7gm/dl
Albumin::3.8gm/dl
Smear: normocytic normochromic

HIV RAPID TEST :: POSITIVE

Provisional diagnosis::

Gastroenteritis

Treatment::
Iv Fluids
Inj.zofer
Tab.sporolac
Cap radotril
Inj.pan 40
Inj.kcl 1amp in 500ml Ns







Comments

Post a Comment

Popular posts from this blog

A 68YRS WITH ALTERED SENSORIUM UNDER EVALUATION SECONDARY TO ?SEPTIC ENCEPHALOPATHY WITH TYPE 2DM SINCE 25YRS WITH HTN SINCE 20YRS WITH LEFT 3RD TOE NON HEALING ULCER

Image
This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent. Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This Elog also reflects my patient centered online learning portfolio. I have been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment Chief complaints:: A  68yr Rtc bus driver came with C /o ulcer over the left foot since 1month Blackish discolouration of left 3rd toe since 15days Burning micturition  since 15days Altered sensation since 3days History of present illness:: Patient was apparently asymptomatic 1month ago then he had
Read more

General Medicine Internship Real Patient OSCEs towards optimizing clinical complexity

Image
Introduction:  This online E-log Entry Blog is an objectively structured clinical examination method to assess the clinical competence during the course of my General Medicine Internship rotation (June'2023-August'2023) by reviewing the case reports shared below and to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs for questions surrounding the clinical vignettes borrowed from the E Log Book. Note:  The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family. AMC CASE NO.1  PATIENT CAME TO OPD WITH C/O VOMITINGS SINCE 1WEEK YELLOWISH DISCOLOURATION Of EYES SINCE 1WEEK Detailed history :::: patient was a AUTODRIVER  by occupation works daily from 7am  to  9pm  developed . VOMITINGS SINCE 1WEEK YEL
Read more

22YR OLD WITH VOMITINGS AND ICTERUS

Image
This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent. Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This Elog also reflects my patient centered online learning portfolio. I have been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment CHIEF COMPLAINTS:::  PATIENT CAME TO OPD WITH C/O VOMITINGS SINCE 1WEEK YELLOWISH DISCOLOURATION Of EYES SINCE 1WEEK HISTORY OF PRESENT ILLNESS:: PATIENT WAS APPARENTLY ASYMPTOMATIC 1WEEK AGO THEN HE DEVELOPED VOMITINGS 3-4 EPISODES/DAY WITH FOOD MATERIAL AS CONTENT, NON BILIOUS, NON BLOOD TINGED,
Read more