CBBLE UDHC SIMILAR CASE STUDY

​18 yr 

old female patient came with c/o diffuse pain abdomen since 2 weeks 

C/o  vomitings since 5 days 

C/o  loose stools since 2 days 

C/o Fever on and off since 1 week 


HOPI: patient was apparently asymptomatic 2 weeks back then she had diffuse abdominal pain after eating hostel food (5 other people also had similar complaints ) treated conservatively 

From 5 days pt had increased intensity of pain in the lower abdomen- colicky type , intermittent , not radiating to back, sudden in onset  pain not relieving on taking medication and associated with vomitings 

Vomitings - since 5 days (15-20 episodes )

Non bilious , non projectile , food as content . 

Loose stools from 2 days - watery in consistency , no blood in stools 

Fever on and off since 1 week not associated with chills and rigors 

Past history : not a k/c/o DM , HTN, Asthama , Epilepsy , TB , Thyroid .

 O/E: pt is c/c/c 

No signs Of dehydration.

Temp: AFEBRILE 

Bp: 120/80 mmhg 

PR : 87 bpm 

CVS : S1S2  

RS : BAE  

CNS : NAD 

P/A: soft , no guarding , no rigidity , non tender , Bs .

P/R: No external skin changes 

Sphincter tone normal . Rectum collapsed

Gloved finger stained with faecal matter 

X - ray erect abdomen  shows Dilated bowel loops with air fluid levels 

Usg abdomen and pelvis : Dilated  small and large bowel loops with sluggish peristalsis suggestive of paralytic ileus and minimal inter bowel fluid . 

Hb: 6.9 GM/dl 

Dx: ACUTE GASTROENTERITIS WITH PARALYTIC ILEUS SECONDARY TO ELECTROLYTE IMBALANCE ?

Rx: 1) NBM till further orders 

      2 ) IVF 2 RL , 1 Ns @ 60 ml/ hr

      3) Inj . PAN. 40 mg IV /od 

      4) Inj. Zofer 4 mg IV /od 

      5) Inj tramodol in 100 ml ns 

      6)Inj ciproflox 200 mg IV BD 

      7) Inj metrogyl 100 ml Tid 





Attachment.png

Comments

Post a Comment

Popular posts from this blog

A 55 yr old male

Image
"This is an online E log book to discuss our patient\"s de-identified health data shared after taking his/her/guardian\"s signed informed consent.  Here we discuss our individual patient\"s problems through series of inputs from available global online community of experts with an aim to solve those patient\"s clinical problems with collective current best evidence based inputs.  I\"ve 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 clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.   CASE :  A 55year old male, toddy climber by occupation came with complaints of pain in abdomen and fever . FOLLOWING IS MY ANALYSIS OF THE PATIENT\"S PROBLEM : The problems in order of priority I found are : 1) Severe pain abdomen since 10 days 2) Fever since 7 days. 3) Decreased appetite since 7 days. ...
Read more

75 yr old male

  CBBLE  UDHC SIMILAR CASE STUDY         CBBLE  UDHC SIMILAR CASE STUDY A 75 year old male was brought to the casualty for further care for known case of CVA diagnosed 1 week back. HISTORY OF PRESENTING ILLNESS The patient was apparently asymptomatic 10 days back when he observed deviation of mouth. associated slurring of speech not associated with drooling of saliva.The patient also complained about throat pain and difficulty in swallowing(solids and liquids equally) 10 days back for which Upper GI endoscopy was done(which showed no abnormality). This lead to the patient's reduced appetite. The patient also complained of generalised weakness since 10 days. This was also associated with headache(diffuse) and approx. 12 episodes of vomitings lasting for 2-3 days 10 days back. The patient also complains of continuous hiccups since 3 days which gets intermittently relieved by itself. The patient is a k/c/o DM 2 and HTN which was diagnosed 10 years back wh...
Read more