1601006119 LONG CASE

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A 65 year old female,homemaker, resident of narketpally, came to the hospital with the chief complaints of:-

Complaints :

. Fever since 5 days

. Pain abdomen since 4 day's

. Vomitings

. Loose motions since 4 day's

History of presenting illness :

Patient was apparently asymptotic 5 days back , then she developed FEVER  which was 

- sudden in onset

- low grade

- associated with chills and rigor

- which is relieved by medication.

Pain abdomen :

Pain in the right lower quadrant of abdomen which is cramp like dull ache in nature

Which was sudden in onset

Relieved by taking medication

Vomitings :

- 3 episodes / day

- nonprojectile , content - has food particles

- non bilious

Loose stools :

3 to 4  times a day, subsided with medication , 

PAST HISTORY :

She is a known case of DM , HTN ,since 8 years

She is on medication for that

Not a known case of asthma, TB , Epilepsy,CAD, thyroid, stroke.

FAMILY HISTORY : no similar complaints

No history of asthma, TB,CAD, thyroid,stroke , diabetes , hypertension.

PERSONAL HISTORY :

Diet - mixed

Appetite- normal

Sleep - disturbed due to abdominal pain

Bladder - regular

Addictions : toddy occasionally

GENERAL EXAMINATION :

Patient is concious , coherent , co operative ,moderately build moderately nourished

Pallor  present

No icterus, no clubbing, no koilonychia, lymphadenopathy, edema.

VITALS : temp - a febrile

             B.P- 110/80 mmHg

               RR -18 CPM

PER ABDOMINAL  EXAMINATION :

Inspection : fullness / generalized distension

           

       Skin over abdomen normal

                   No scars , sinuses , engorged veins

                   No visible pulsations,

                     Umblicus - normal

palpation :  no local rise of temperature

    No tenderness, no rigidity, no guarding

      No organomegaly

   ( liver, spleen , kidney - not palpable )

Percussion : tympanic note heard  all over abdomen, shifting dullness  & fluid thrill absent

Ascultation : bowel sounds normal

RESPIRATORY SYSTEM :

Bilateral air entry present

Vesicular breath sounds heard , no added sounds.

CVS :

S1 & S2 heard , no murmurs

Apex beat : left 5 th intercoastal space in the medial to mid clavicular line.

CNS :

Patient is concious, speech  normal , cranial nerves intact ,  

INVESTIGATIONS :

. CBP

. Blood grouping

. CUE 

. RFT

. LFT

. Stool culture

. RBS

CUE :

 RFT :

 LFT :

TREATMENT GIVEN :

Differential diagnosis  :.                                    . Food poisoning

 . Inflammatory bowel syndrome

  . Malabsorption

   . Diabetic ketoacidosis

Provisional diagnosis :

Acute gastroenteritis