LONG CASE
A 34 year old female patient who is a farmer by occupation and is resident of choutuppal came to opd with chief complaints of -
1. Vomitings since 3 days
2. Abdominal pain since 3 days
HISTORY OF PRESENTING ILLNESS -
Patient complains of vomiting since 3 days which contains food particles ( occurring after intake of food ) 3-4 episodes in a day , yellowish in colour non projectile and non bloodstained .
History of abdominal pain since 3 days which she describes as diffuse and intermittent associated with nausea , throbbing type aggravated with eating.
Along with vomiting and abdominal pain patient also has generalised weakness affecting her daily activities.
Patient was apparently asymptomatic 1 month back then she developed fever which was sudden in onset associated with chills and rigor , she also had 2-3 episodes of vomiting with pain in abdomen and watery , small volume, non blood stained loose stools . After which patient went to hospital and was diagnosed with anemia with Hb of 5.2gm% . She was advised admission in the hospital to which she refused and was started on oral iron therapy. She also ate iron rich food at home .
No history of burning micturition, urgency , increased frequency, Dyspnea , paroxysmal nocturnal dyspnea or any bleeding manifestations.
DAILY ROUTINE-
Patient wakes up at 6 am and does her daily morning activities then she has her breakfast at 9 am . She packs her lunch and leaves for work ( farmer ) where she has her lunch at 1 pm . She comes back home by 6 in the evening and does household chores has her dinner at 8 pm and sleeps by 9 pm .
Now because of weakness she is unable to do her daily work .
MENSTRUAL HISTORY-
Menarche at the age of 14 years
Cycles - 5/30 regular ( delayed by 5 days )
Usage of cloth
Associated with dysmenorrhea and presence of clots .
MARITAL HISTORY -
She was married at the age of 16 years
Non consanguineous marriage.
OBSTETRIC HISTORY-
She has 2 kinds
LSCS w as done in both the pregnancies. While 2nd pregnancy patient has history of blood transfusion .
PAST HISTORY-
No similar complaints in past
Patient is not a known case of Diabetes Mellitus , Hypertension, Epilepsy, CAD or any thyroid abnormality.
FAMILY HISTORY-
No significant family history
PERSONAL HISTORY-
Diet - mixed
Appetite - normal
Bowel and bladder- regular
Sleep - adequate
No addictions
GENERAL EXAMINATION-
Patient is conscious coherent and cooperative
Moderately built and nourished
Pallor- ++
Icterus - absent Cyanosis- absent
Clubbing- absent
Lymphadenopathy- absent
Edema- absent
VITALS -
Temperature- a febrile
BP - 110/70 mm of hg
Pulse rate - 65 bpm
Respiratory rate - 17 cpm
SYSTEMIC EXAMINATION-
ABDOMEN EXAMINATION-
INSPECTION-
Shape - round large with no distension
Umbilicus - inverted
Equal symmetrical movements in all quadrants with respiration
No visible pulsations , palpations , dilated veins or localised swelling
LSCS scar present in lower abdomen, hyperpigmented
Hernial orifices are free
PALPITATION -
No local rise of temperature
Diffuse tenderness ( present in left lumbar , umbilical, hypo gastric areas)
Deep palpitations-
No organometaly
PERCUSSION- liver dullness heard at 5th intercostal space
AUSCULTATION-
Bowel sounds present
No bruit heard
Cardiovascular system-
JVP - not raised
Visible pulsations: absent
Apical impulse : left 5th intercostal space in midclavicular line.
Thrills -absent
S1, S2 - heart sounds heard
Pericardial rub - absent
Respiratory System-
Patient examined in sitting position
Inspection:-
oral cavity- Normal ,nose- normal ,pharynx-normal
Shape of chest - normal
Chest movements : bilaterally symmetrically reduced
Trachea is central in position.
Palpation:-
All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 5th ICS,
Chest movements bilaterally symmetrical
AUSCULTATION
BAE+, NVBS
Central Nervous System-
Higher mental functions intact
No focal neurological deficit’s present
PROVISIONAL DIAGNOSIS-
ACUTE GASTRITIS WITH ANEMIA
INVESTIGATIONS -
1. Hemogram
2. Peripheral smear -
RBC - predominantly microcytic hypochromic with few macrocytes , pencil forms
WBC- increased count on the smear
PLATELETS- adequate
3. Reticulocyte count - 1.8%
4. Stool for occult blood - negative
5. Chest X-ray -
6. ECG -
7. Blood urea - 25 mg/dl
8. Serum creatinine- 0.6 mg/ dl
9. USG -
10. Serum electrolytes-
Sodium - 141 mEq/dl
Potassium- 5.4 mEq/dl
Chloride - 1010 mEq/dl
DIAGNOSIS:-
ACUTE GASTRITIS WITH NUTRITIONAL ANEMIA
SHOWING ASYMMETRIC KIDNEY ON USG
TREATMENT-
IV fluids ns 75ml/hr
INJ pan 40 mg/ IV /od
INJ Zofer 4mg/IV
INJ optineuron 1 amp in 500ml ns/ IV/od
T.PCM 650 mg od
Syp.Sucralfate 10ml/tid
Syp. Cremaffin citrate 15ml
INJ vitkofol 1000mcg/IM/od
T.orofer xt/po/od
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SHORT CASE
A 35 year old female resident of Nakrikal who is a daily wage labourer by occupation came with
CHIEF COMPLAINTS of :-
1. Fever since 1 week
2. Headache since 1 week
HOPI :-
Patient was apparently asymptomatic 1 week back then she developed fever which is intermittent in onset ( on and off ) increasing at night time and decreasing in the morning associated with chills and headache ( increased headache leading to increase in fever ).
Fever is relieved by taking anti pyretic . No history of nausea , vomiting , rash or body pain .
History of unilateral headache since 1 week which is severe throbbing pain in left fronto parietal occipital region radiating to the neck due to exposure of stress . Pain is causing her to wake up at night ( inadequate sleep ) .
Headache is associated with vomiting ( just 1 episode ) phonophobia and blurring of vision ( history of change in spectacles) , decreased regular physical activity , tingling sensation in hand and feet . It relieves on taking rest and medication .
No history of aura , photophobia , depression , irritability, cravings , diarrhoea/constipation.
She has history of burning micturition since 5 days associated with decreased urine output, decreased frequency, left loin pain which is dragging type pain ( since 1 day ) . No aggrevating and relieving factors . No history of urgency, hematuria , nausea , vomiting .
DAILY ROUTINE:-
She gets up at at around 5 in the morning does her daily chores and gets her kids ready for school then she has breakfast at 8:30 or 9 am and then sleeps for sometime before she goes to work which she has stopped going since 6 years .
PAST HISTORY:-
Similar episode one year back .
Not a known case of Diabetes, hypertension, epilepsy, cardiovascular disease and tuberculosis.
History of hypothyroidism 10 years back for which she is on daily thyroxine ( 75 mg ) supplements.
History of renal stones in the left kidney 6 years back for which she took conservative treatment.
FAMILY HISTORY :-
No significant family history .
PERSONAL HISTORY:-
Diet - mixed
Appetite - decreased
Sleep- inadequate
B&B - she is constipated
Addictions- none
NO H/o is any drug allergy
GENERAL EXAMINATION:-
Patient is conscious, coherent and cooperative
Well oriented to time. Place and person .
Moderately built and nourished
O/E - thyroid appears normal
Clubbed- absent
Cyanosis- absent
Icterus - absent
Generalised lymphadenopathy- absent Edema - absent
FEVER CHART :-
VITALS:-
Temp - 99 F
PR - 84bpm
RR- 20 cpm
BP - 100/70 mm of Hg
SYSTEMIC EXAMINATION:-
CVS - S1 S2 heard , no murmurs present
RESP - bilateral Air entry present
normal vesicular breath sounds heard
ABDOMINAL-
examination of oral cavity is normal
**Inspection
-shape-normal(rounded)
-no flank fullness is seen.
-skin-no scars seen ,presence of striae.
-no dilated veins seen
-Movements of abdominal wall-no visible peristalsis,no visible pulsations
-umbilicus-inverted.
**Palpation
-tenderness-hypogastrium and left lumbar region
-warmth- present (fever)
-rigidity,guarding is absent
*no organomegaly, normal bowel sounds heard
CNS:no focal deficits are found.
Higher mental functions- normal
Brudzinski’s sign - absent
Kernig’s sign - absent
PROVISIONAL DIAGNOSIS:-
Migraine/ Left Renal Calculi / UTI
INVESTIGATIONS:-
Complete urine examination:-
Hemogram :-
Thyroid profiles :-
USG :-
TREATMENT:-
Inj-optineuron 1amp in 100ml of NS OD
IvF-@70ml/hr
Tab nitrofurantoin 100mg
Tab pan
Tab naproxen 250mg
Bp,temp,RR,PR check 4th hrly
Tab thyronorm 25mcg
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