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 ) 

Regular cycles, flow is for 5 days , associated with clots and pain.

Marital history:

Age of marriage at 2009 (16)yrs, non consanginous marriage

Obstetric history:

 P2L2 - has 2 children 2 boys , c-section,As per her wish,immunized as per schedule.

1st child- 13 years(2010)(17) born

During 2nd pregnancy she had a transfusion done at 9month for anemia.

2nd child- 9 years(2014)(21) born admitted in NICU (lbw).

Breastfed after 1 day

GENERAL EXAMINATION:

         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.

Temp:98.6 F

SPO2: 99%@ RA

ABDOMEN EXAMINATION:

Inspection - 

          Umbilicus - inverted
          All quadrants moving equally with respiration

      LSCS  transverse scar is seen over the supra pubic region,hyperpigmented.
        No   sinuses and engorged veins , visible pulsations. 

         Hernial orifice are free

Palpation -  no local rise of temperature

    

    Diffuse tenderness is seen over abdomen.

No rebound tenderness

     no palpable spleen and liver

Percussion - live dullness is heard at 5th intercoastal space

Auscultation- normal bowel sounds heard. 

CARDIOVASCULAR SYSTEM:

Inspection : 

• Shape of chest- elliptical 
• No engorged veins, scars, visible pulsation 

Palpation :

•  Apex beat can be palpable in 5th inter costal space
• No thrills and parasternal heaves can be felt

Auscultation : 

• 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 

7.Blood urea: 25mg/dl 

8.serum creatinine-0.6 mg/dl

9.ultrasound:

10.serum electrolytes

 Sodium-141mEq/dl

Potassium-5.4 mEq/dl

Chloride-101mEq/dl

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