A 20 YR OLD FEMALE WITH ACUTE GASTROENTERITIS

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🩺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. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment. I am Nomika Alli (Roll no 179) of 6th Sem, MBBS.

A 20 yr old female came to OPD on 20-12-2022 4:36 pm with chief complaints of left low Back ache radiating to umbilicus since 4 days, vomiting since one half day and loose stools since one day.

HISTORY OF PRESENT ILLNESS:

This patient is a 20 yr old female,  B.Sc. Nursing student by occupation. The pt. was apparently asymptomatic 4 days back, then she developed low back pain radiating to umbilicus C/O one episode of vomiting which was non projectile & contained food particles one half days ago  . She had loose stools since 1 day which were 5-6 episodes per day ( non blood stained).

H/O food intake on Sunday (?? outside)

No H/O fever, SOB, Headache. 

HISTORY OF PAST ILLNESS:

Not K/C/O  DM/ HTN/ CVA/ CAD/ Epilepsy/ TB/ Asthma / thyroid

no blood transfusions

TREATMENT HISTORY: 

not significant.

SURGICAL HISTORY;

not significant.

PERSONAL HISTORY:

• unmarried
• student by occupation
• appetite: normal
• mixed diet
• bowels: loose stools
• micturition: normal
• no known allergies
• no addictions

FAMILY HISTORY: 

not significant .

MENSTRUAL HISTORY:

• AOM: 16yrs
• LMP: dec 4th

GENERAL EXAMINATION:

• TEMP: afebrile
• PR: 85 bpm
• RR: 18 cpm
• BP: 120/80 mmHg
• SPO2: 98% @ RA
• GRBS: 118 mg%
• pallor: +ve
• icterus: -
• clubbing: -
• cyanosis: -
• lymphadenopathy: -
• edema: -

SYSTEMIC EXAMINATION:

CVS:  

• S1, S2 heard
• no thrills
• no murmurs

RESPIRATORY SYSTEM:

• BAE+
• NO DYSPNOEA
• NO WHEEZE
• CENTRAL POSTITON OF TRACHEA
• VESICULAR BREATH SOUNDS HEARD
• no added sounds

ABDOMEN:

          Shape of abdomen: scaphoid

          tenderness: +VE  IN UMBILICAL REGION 

          no palpable mass

          No free fluid 

          no bruits 

          no organomegaly

          normal hernial orifices

          bowel sounds+

CNS: 

          C/C/C to time, place, person

          No signs of meningeal irritation 

          no focal neural deficit found

          normal speech

          functions of cranial nerves, motor & sensory system are normal

Reflexes:  

       biceps triceps supinator knee ankle

right ++       ++          ++             ++         ++

left   ++        ++          ++             ++         ++

CEREBELLAR SIGNS:

Finger nose in coordination: yes

Knee- heel in coordination: yes

GAIT: normal

MUSCULOSKELETAL SYSTEM:     N

SKIN : N

EXAMINATION OF BREAST, ENT, TEETH & ORAL CAVITY, HEAD & NECK:

NORMAL

PROVISIONAL DIAGNOSIS:

?? ACUTE  GASTROENTERITIS  WITH  LOW BACK ACHE

under evaluation

INVESTIGATIONS:

Pallor + ve

ECG

  

HEMOGRAM & CUE 

LFT & RFT 

USG

CHEST X RAY

LATERAL VIEW X RAY

X RAY ABDOMEN & PELVIS

TREATMENT:

1. INJ. METROGYL 500mg IV/ IM
2. INJ. Pan 40 mg IV/ OD
3. INJ. ZOFER 4mg IV/ OD
4. Tab. ULTRACET PO/ BD
5. Fluids NS @ 100 ml/ hr
6. INJ. CIPROFLOXACIN 200mg IV/ BD
7. Tab SPORLAC DS PO/ TID
8. ORS sachets 200ml after each episode of stool (diarrhoea)