Long case- 1601006099

This is an online E log book to discuss our patient's de-identificatied health data shared after taking her signed informed consent. 

LONG CASE: 1601006099 

A 65 yr old female, resident of narketpally, a house wife, came to the hospital with Chief complaints of

- Fever with chills since 8 days. 

- Pain abdomen and loose stools since 6 days.

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 8 days back, then she developed

- Fever, which was sudden in onset, low grade, associated with chills and rigors and relieved on medication.

- Pain in abdomen 6 days ago, sudden in onset, continuous, cramping/dull aching type, involving all quadrants and aggravated with food intake.

- Associated with 2-3 episodes/day of vomiting which was non bilious, non projectile and watery in consistency.

- Multiple episodes of loose stools 6 days back, which was watery and in large volume, no tenesmus, no mucous or blood in stools.

- History of burning micturition since 4 days, no froth/blood.

- No hematemesis/malena.

PAST HISTORY:

- She is a known case of diabetes since 10years

- History of hypertension since 10years

- No history of Tuberculosis, asthma, epilepsy, thyroid disorders, CAD, stroke.

DRUG HISTORY:

- Diabetes: Metformin 500mg

- Hypertension: Telmisartan 40mg

PERSONAL HISTORY:

- Diet mixed. 

- Sleep disturbed due to frequent loose stools.

- Appetite decreased.

- Bowel movements- irregular 

- Bladder- urgency and incontinence

- No known allergies

- No alcohol 

- No smoking 

FAMILY HISTORY:

Not significant 

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Well oriented to time place and person. Moderately built & Well nourished. 

- Pallor: present

- No Icterus, Koilonychia, Clubbing, Lymphadenopathy, Edema.

Vitals

- Temperature: afebrile

- BP: 110/80 mm hg

- Pulse: 92 bpm

- Respiratory rate: 20 cycles/min

- SpO2 96%

SYSTEMIC EXAMINATION:

Per Abdominal examination 

  Inspection:

- Generalised distention/fullness is seen.

- Shape: distended 

- Flanks full

- Umbilicus inverted

- Movements with respiration: equal in all quadrants. Rises during inspiration and falls during expiration.

- No visible pulsations.

- Skin over abdomen: Multiple vertical stretch marks, horizontal scars.

  Palpation:

- No local rise of temperature. 

- Tenderness: diffuse.

- Liver, Gall bladder, Spleen impalpable.

  Percussion:

- Shifting dullness: not present

- Fluid thrill: not present

Auscultation: 

- Bowel sound heard

Other system examination

CVS

- S1 , S2 heard

- Apical impulse in 5th intercostal space lateral to mid clavicular line

- No murmurs

Respiratory system

- Bilateral air entry

- Normal vesicular breath sounds

- Bronchial breath sounds hear

- Trachea in the midline 

CNS      

- Gait normal 

- Sensations normal 

- Cranial nerve normal

- Reflexes preserved

INVESTIGATIONS:

1. Stool examination & culture

2. Haemogram

3. Urine examination:

    Increased pus cells in urine

4. Urine Protein/Creatinine ratio

 5. Renal Function tests 

6. Fasting blood sugar

7. Glycated Haemoglobin 

PROBABLE DIAGNOSIS:

ACUTE GASTROENTERITIS 

Treatment:

Tramadol inj

Ondansetron inj 

Frusemide inj 

Cefixime Tab