1801006019- long case
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan
CASE
A 30 yr old female presented with chief complaints of weakness since one month,
vomiting since 2 days and pain abdomen since 3 days.
HISTORY OF PRESENT ILLNESS:
Patient of 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
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.
PAST HISTORY:
No similar complaints in the past. Not a k/c/o Hypertension,Diabetes,Asthma, Tuberculosis, Epilepsy,Thyroid abnormalities.
FAMILY HISTORY:
No significant family history.Her mother has Diabetes and hypothyroidism since 10 years.
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.
PERSONAL EXAMINATION:
DIET: Mixed
Appetite: decreased
Bowel and bladder: regular
Sleep : Adequate
No Addictions and No afood or drug allergies
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
Koilonychia:Absent
Clubbing: 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
Probable diagnosis:
Acute Gastritis .
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
6.ECG
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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