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

61YRS WITH K/C/O BRONCHIAL ASTHMA AND K/C/O CAD UNDERWENT S/P PTCA

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 with c/o cough since 18months Shortness of breath since 1yr Chest tightness and epigastric pain since 1yr History of present illness:: Patient was apparently asymptomatic 18months back then he developed  cough insidious in onset gradually progressive,dry, ...
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 TING...
Read more

45 yr old male with shortness of breath

Image
Chief complaints::   A   45 year old man came to the casualty complaining of  shortness of breath since 10 days.and swelling of lower limbs since 10 days History of present illness::: ..He was apparently asymptomatic six years ago, then he had an episode of fever for which was admitted to the hospital. . He was diagnosed with malaria. .He was diagnosed with Diabetes Mellitus as well. Then, 3 years ago , he had an another episode of fever for which he consulted a physician  He was found to have Viral Pyrexia and was diagnosed with Hypertension. Then around 1 year ago , one morning he had an episode of weakness of the right arm for which he was advised to undergo physiotherapy.  After 6 months of physiotherapy, the family thought he might get dependent on it so discountined. On September 2nd 2021, he came to the casualty with complaints of generalised swelling and shortness of breath since 10 days. Which was insidious in.onset gradually progressive from grad...
Read more