1601006067 - Final Year Practical Short Case
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A 25 year old female tailor by occupation from Thummelagudam came to OPD with chief complaints of
1. Vomiting
2. Loose stools since morning
History of presenting illness :
- She was apparently asymptomatic few hours back then she developed vomiting
- It was sudden in onset , non bilious , non projectile , 20 episodes , mainly water as content
- It was associated with burning type of pain abdomen involving all the quadrants
- Loose stools of 6 episodes , watery in consistency , not associated with blood or mucus
- No h/o fever
- No h/o intake of food from outside
Past History :
- History of similar complaints 1 year back
- Not a known case of Diabetes , HTN , TB , Asthma , Epilespsy
- H/o of 2 previous LSCS
General Examination :
- Consent was obtained
- She was Conscious , Coherent , Cooperative , Moderately built & nourished
- Pallor present
- No Cyanosis , Clubbing , Lymphadenopathy , Edema
VITALS :
Temperature - Afebrile
Pulse Rate - 96 bpm
Blood Pressure - 100/70 mmHg
Respiratory Rate - 18 cpm
GastroIntestinal System :
ORAL CAVITY :
1. Lips - Dry
2. Teeth - Normal
3. Gums - Normal
4. Tongue - Dry
5. Tonsils - Normal
PER ABDOMEN :
INSPECTION -
1. Shape - Scaphoid
2. Umbilicus - Central & inverted
3. Movements in accordance with respiration
4. No visible pulsation
5. No scars , sinuses , engorged veins
PALPATION -
1. Mild tenderness in all quadrants of abdomen
2. No organomegaly
PERCUSSION -
1. Tympanic note
2. Liver dullness elicited at 5th intercostal space
AUSCULTATION -
Bowel sounds present
Investigations :
1. Complete Blood Picture
2. Complete Urine examination
3. GRBS - 102 mg/dl
Provisional Diagnosis :
Acute Gastroenteritis
Treatment :
1. IV Fluids - NS , RL , DNS 150 ml/hr
2. Inj. Pantop 40 mg OD
3. Inj. Zofer 2 cc TID
4. Inj. Metrogyl 100 mg TID on day 1 & 3
5. Vitals monitored 4 hrly
6. GRBS 6 hrly
7. Inj. Monocled 1 gm BD on day 1
8. Tab. Doxycycline 100 mg TID
9. Tab. Sporolac DS/PO/BD
10. ORS sachets - 2 in 1 L water , 200 ml after each episode
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