1801006095 CASE PRESENTATION
long case
Chief complaints-
A 30 yr old female presented with chief complaints of weakness since one month,
vomiting since 3 days and pain abdomen since 3 days.
History of presenting illness
Patient was apparently asymptomatic 1month ago then she developed fever which is sudden in onset , intermittent with no aggrevating and relieving factors associated with vomiting and diarrhoea.vomitings are non projectile,non bilious,food particles as content ,2-3 times per day for about a week . Diarrhoea which are large volume stools ,watery in consistency,non blood stained,non foul smelling,10 times per day for about a week.she also complaints of lower back pain,localised , insidious onset gradually progressive,dragging type aggrevates on doing work relieves by rest.No history of trauma to back. She also complaints of generalized weakness since 1month. Then she visited our hospital and here diagnosed with anemia with haemoglobin 5.2gm/dl and advised for admission in the hospital ,but she denied admission and opted for treatment on out patient basis.she is on oral iron supplements since 1 month. At present patient came with complaints of pain abdomen since 3 days insidious in onset,diffuse in nature associated with vomiting 3 times per day since day before yesterday containing food particles,non projectile,bilious vomiting not associated with fever.
No h/o urgency,hesitancy ,burning micturition.No h/o orthopnea,paroxysmal nocturnal dyspnea.No h/o bleeding manifestations
PAST HISTORY:
No similar complaints in the past. Not a k/c/o Hypertension,Diabetes,Asthma, Tuberculosis, Epilepsy,Thyroid abnormalities
PERSONAL HISTORY
DIET: Mixed
Appetite: decreased
Bowel and bladder: regular
Sleep : Adequate
No Addictions and No food or drug allergies
DAILY ROUTINE:
She is farmer by occupation.Wakes up at 6AM does her morning routine and drinks a cup of milk daily about 100 ml.Does her breakfast at 9am,packs her lunch and goes to work.she will have lunch at 1 pm near field.she returns to home at 6 pm and does her household chores and has her dinner by 8 pm ,sleeps at 9pm.
But because of these illness now her lifestyle is completely changed she now cannot do any of field work and also she is not able to do her household work too.Her mother who is living with them is doing all her work and helping her.she now used to wakeup at 6 am and does her breakfast and sits for a while but because of backpain she cannot sit for a long time she takes rest. Like this it continuous throughout the day where she sometimes sits,takes rest and has her lunch/dinner.
FAMILY HISTORY:
No significant family history.Her mother has Diabetes and hypothyroidism since 10 years.
Treatment HISTORY
She received blood transfusion during her second pregnancy.
Drug history
Iron and folic acid tablets
Omeprazole ,domperidone
sefexim
Vitamin supplements
Nutritional history:
24hr recall method
Mrng at 7am drinks cup of milk and small cup of tea.
Brrakfast -2cups of rice with dal
Lunch-2cups of rice with dal
At 5pm drinks a cup of tea
Dinner at 8pm-1cups of rice with dal
Total daily intake-approximatly 2500kcal per day.
MENSTRUAL HISTORY:
She attained menarche at 14 years, uses 2 clothes per day (5/30 )
By taking prior consent.she was examined in a well lit room .
Patient was consious,coherent,cooperative.he is poorly built and malnourished and well oriented to time place and person.
Pallor: PRESENT
Icterus: Absent
Cyanosis-absent
Clubbing-absent
Koilonychia:Absent
Lymphadenopathy: Absent
Edema :Absent
VITALS:
Pulse rate : 80 bpm,regular rhythm normal volume .
Respiratory Rate: 15Cycles/min
Blood pressure: 110/80mm hg in right arm examined in sitting position.
ABDOMEN EXAMINATION:
All quadrants moving equally with respiration
No sinuses and engorged veins , visible pulsations.
CARDIOVASCULAR SYSTEM:
- Shape of chest- elliptical
- No engorged veins, scars, visible pulsation
- Apex beat can be palpable in 5th inter costal space
- No thrills and parasternal heaves can be felt
- S1,S2 are heard
- no murmurs
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion: resonant bilaterally
Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard.
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
CEREBELLAR FUNCTION
Normal function
No meningeal signs were present
Investigations:
1.Haemogram
2.peripheral smear:
RBC: predominantly Microcytic Hypochromic with few macrocytes,pencil forms.
WBC: Increased counts on smear.
Platelet: Adequate.
3.Reticulocyte count:1.8%
4.Stool for occult blood: Negative
5. Chest xray
7.Blood urea: 25mg/dl
9.ultrasound:
Diagnosis:
Acute Gastritis resolved with dimorphic anemia with right sided small kidney.
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
70year old female resident of narketpally came to the hospital with complaint of fever from 4 days.
Date of admission:10/03/2022
History of present illness:
Patient was apparently symptomatic 20days back then she complained of fever which is insidious in onset ,highgrade intermittent type of fever associated with chills and rigor,relieved on medication and again it appears.
She visited our hospital and blood test were done and prescribed medication and fever got relieved
Since 4days she again complained of fever which is highgrade, intermittent type associated with chills and rigor,no evening rise of temperature aggravated on eating food, relieved upon medication (2tabs.perday of paracetamol).
Then she visited a local hospital there her BP checked and doctor confirmed that she is hypertensive and prescribed medication and she taken the tablets and tablet sheet prescribed by doctor were completed and she is not taking the tablets.
Doctor prescribed medication for control of fever but fever appears again after discontinuation of medication and he suggested to visit our hospital (in think of malaria,dengue)
She also complained of slight headache during fever attack.
No history of cough,cold,myalgia,weight loss,sore throat.
No history of pain abdomen , constipation,vomitings.
No history of joint pains,epistaxis,retro orbital pain.
No history of burning micturition.
No history of palpitations,fatiguability,shortness of breath.
Past history:
Not a K/C/O of DM,TB,Epilepsy.
No history of blood transfusion.
History of left eye surgery for pterygium.
Personal history:
Appetite:Normal
Diet:Mixed
Sleep: Adequate
Bowel and bladder habits:Regular
No Addictions.
Family history:Insignificant
General Examination:
Conscious, coherent, co-operative
Moderately built and nourished.
Systemic Examination:
CNS EXAMINATION:
Higher mental functions intact
Cranial nerve ,sensory,motor system examination:normal
Provisional diagnosis:
Fever and Normocytic normochromic anemia under evaluation with AKI .
Investigations:
14/02/2022:
Hemogram:
TREATMENT
IVF NS ,RL @100ml/hr
Inj.PAN 40mg I.V/OD
Temp charting 4th hourly
Inj .OPTINEURIN 1amp in 100ml NS I.V/OD
Inj NEOMOL 1gm I.V SOS(if temp >101°F)
Tab.DOLO 650mg PO/TID
Inj.MONOCEF 1gm I.V BD
11/03/2022:
IVF NS,RL @50ml/hr;DNS @100ml/hr
Inj MONOCEF 1gm I.V BD
Inj PAN 40mg I.V/OD
Inj.OPTINEURIN 1amp in 100ml NS I.V/OD
Strictly I/O charting
12/03/2022:
O/E:
BP:130/70mmof hg ,RR:24cycles/min,pulse rate:79bpm
IVF NS,RL @50ml/hr
Inj.PIPTAZ 2.25gms I.V TID
Inj OPTINEURIN 1amp in 100ml NS I.V/OD
Strictly I/O charting
Inj.PAN 40mg I.V/OD
Temp charting 4th hourly
Tab.DOLO 650mg PO SOS
Inj.NEOMOL 1gm I.V SOS
Tab.DOXY 100mg PO BD
Plenty of oral fluids
Tab. NODOSIS 500mg PO TID
BP,Pulse rate 4th hourly monitoring
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