Hello everyone...I'm an intern in medicine department. I would like to present here, one of my case experiences in this initial phase of my internship .
Case discussion :
CHIEF COMPLAINTS : A 38 year old female presented to the OPD with chief complaints of vomitings and loose stools since 1day.
HOPI : Patient was apparently asymptomatic 1day
back.Then she had ...
back.Then she had ...
*Vomitings: 10 episodes , non-bilious , non- projectile , non-blood stained
*Loose stools : 10 episodes , watery consistency , non-blood stained , associated with generalized weakness and pain abdomen
No H/O fever.
PAST HISTORY : Not a known case of DM,HTN,TB,epilepsy,CAD,CVA.
PERSONAL HISTORY : Diet - mixed
Appetite - normal
Sleep - adequate
Bowel habits - loose stools since
1day
Bladder habits - regular
No addictions
FAMILY HISTORY : No H/O DM,HTN,TB.
DRUG HISTORY : No known and food allergies.
GENERAL EXAMINATION :
- Pt. was conscious, coherent, cooperative
- Moderately built and nourished
- Pallor : present
- No signs of icterus , cyanosis , clubbing , koilonychia , lymphadenopathy , pedal edema.
VITALS : Temp - Afebrile
PR - 120bpm
RR - 27cpm
BP - 100/50mmHg.
SYSTEMIC EXAMINATION :
1) Per abdomen -
Inspection : *Shape : scaphoid
*Umbilicus : central,inverted
*All quadrants moving
equally with respiration
Palpation : Tenderness : present
No Organomegaly
Auscultation : Bowel sounds heard
No bruit
2) CVS - S1,S2 heard
No murmurs
3) RS - Bilateral air entry present
Normal vesicular breath sounds
4) CNS - Pt. is conscious
Speech - Normal
Cranial Nerves - Intact
Motor system - normal
Sensory system - normal
No signs of meningeal irritation
DIFFERENTIAL DIAGNOSIS : Acute Gastroenteritis
Dengue
INVESTIGATIONS : 1) Hemogram : Hb - 5.8 g/dl
TLC - 3,900
Platelets - 47,000
No H/O fever.
PAST HISTORY : Not a known case of DM,HTN,TB,epilepsy,CAD,CVA.
PERSONAL HISTORY : Diet - mixed
Appetite - normal
Sleep - adequate
Bowel habits - loose stools since
1day
Bladder habits - regular
No addictions
FAMILY HISTORY : No H/O DM,HTN,TB.
DRUG HISTORY : No known and food allergies.
GENERAL EXAMINATION :
- Pt. was conscious, coherent, cooperative
- Moderately built and nourished
- Pallor : present
- No signs of icterus , cyanosis , clubbing , koilonychia , lymphadenopathy , pedal edema.
VITALS : Temp - Afebrile
PR - 120bpm
RR - 27cpm
BP - 100/50mmHg.
SYSTEMIC EXAMINATION :
1) Per abdomen -
Inspection : *Shape : scaphoid
*Umbilicus : central,inverted
*All quadrants moving
equally with respiration
Palpation : Tenderness : present
No Organomegaly
Auscultation : Bowel sounds heard
No bruit
2) CVS - S1,S2 heard
No murmurs
3) RS - Bilateral air entry present
Normal vesicular breath sounds
4) CNS - Pt. is conscious
Speech - Normal
Cranial Nerves - Intact
Motor system - normal
Sensory system - normal
No signs of meningeal irritation
DIFFERENTIAL DIAGNOSIS : Acute Gastroenteritis
Dengue
INVESTIGATIONS : 1) Hemogram : Hb - 5.8 g/dl
TLC - 3,900
Platelets - 47,000
2) USG abdomen :
3) ECG :
4) Stool examination :
TREATMENT : IV Fluids - 10 NS , 10 RL @ 100ml/hr
Inj.Pan - 40mg IV OD
Inj.Zofer - 4mg IV TID
Inj.Ciproflox 500mg IV BD
Inj.Metrogyl 500mg IV TID
Inj.Falcigo 60mg IV Stat
Inj.Iron sucrose in 100ml NS IV OD
Inj.Neomol 1g IV SOS
T.Optineuon 1amp in 100ml NS IV OD
T.Redotil 100mg BD
T.PCM 500mg PO TID
T.Sporolac-ds TID
ORS sachets in 1lit water TID
Tepid sponging SOS
3) ECG :
4) Stool examination :
TREATMENT : IV Fluids - 10 NS , 10 RL @ 100ml/hr
Inj.Pan - 40mg IV OD
Inj.Zofer - 4mg IV TID
Inj.Ciproflox 500mg IV BD
Inj.Metrogyl 500mg IV TID
Inj.Falcigo 60mg IV Stat
Inj.Iron sucrose in 100ml NS IV OD
Inj.Neomol 1g IV SOS
T.Optineuon 1amp in 100ml NS IV OD
T.Redotil 100mg BD
T.PCM 500mg PO TID
T.Sporolac-ds TID
ORS sachets in 1lit water TID
Tepid sponging SOS
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