18 year old female with abdominal pain
Kausalya Varma, MBBS 9th semester
Roll no: 59
This is 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 patients 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 comment box is welcome.
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 comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan.
18 YEAR OLD FEMALE WITH DIFFUSE ABDOMINAL PAIN
CHIEF COMPLAINTS:
An 18 year old female came with the chief complaints of diffuse abdominal pain for the past 2 weeks, vomiting for the past 5 days and loose stools for the past 2 days.
HISTORY OF PRESENTING ILLNESS:
- Patient was apparently asymptomatic until 2 weeks ago, after which she developed a diffuse abdominal pain after eating food at her hostel mess. (5 of her other friends have similar chief complaints, were all taken to the hospital and treated conservatively).
- Pain was colicky type, intermittent, non radiating, relieved on taking medication.
- From the past 5 days, patient has an increased intensity of pain in the lower abdomen, suddenly associated with vomitings (3 episodes)- they were non bilious, nonprojectile, contained food particles, pain was not relieved on taking medication.
- Patient has had 15-20 episodes of vomiting since then.
- Patient has been passing loose stools for the past 2 days, around 10-15 episodes, watery in consistency, not associated with any blood, pain is not relieved on defecation.
- Patient has a history of fever for the past 1 week, it was intermittent, low grade, relieved on taking medications.
PAST HISTORY:
Medical history-
The patient has not had a previous episode similar to this.
No other relevant medical history.
Surgical history- No relevant surgical history
GENERAL EXAMINATION:
The patient was conscious, coherant, and co-operative and well oriented to time, place and person. With prior consent, patient was examined in a well lit room, lying down on the bed. She in well built and well nourished.
Pallor- Present
Icterus- Absent
Clubbing- Absent
Cyanosis- Absent
Lymphedenopathy- Absent
Edema- Absent
Koilonychia- Absent
VITALS-
(At admission)
Temperature- 99.4 F
Pulse rate- 108 bpm
Blood pressure- 110/70 mmHg
Respiratory rate- 18 cpm
GRBS- 125mg/dl
Sp02 at room temp- 97%
SYSTEMIC EXAMINATION:
ABDOMINAL EXAMINATION-
Shape – scaphoid, distended
Flanks – free
Umbilicus – Central, inverted
Skin- no sinuses, striae are seen
Dilated veins – absent
Movements of the abdominal wall with respiration is present
No visible gastric peristalsis or intestinal peristalsis
PALPATION:
Superficial Palpation –
No local rise of temperature
Tenderness is present mainly over the right and left iliac regions and the hypogastric regions
Deep Palpation- No hepatosplenomegaly present
PERCUSSION:
Percussion of Liver for Liver Span
Percussion of Spleen- Dull note in percussion
There is no fluid thrill, shifting dullness
AUSCULTATION:
Bowel sounds are heard
RESPIRATORY SYSTEM-
Inspection-
Chest is bilaterally symmetrical
The trachea is positioned centrally
Apical impulse is not appreciated
Chest moves normally with respiration
No dilated veins, scars or sinuses are seen
Palpation-
Trachea is felt in the midline
Chest moves equally on both sides
Apical impulse is felt in the fifth intercostal space
Tactile vocal fremitus- appreciated
Percussion-
The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.
They are all resonant.
Auscultation-
Normal vesicular breath sounds are heard
No adventitious sounds heard
CARDIOVASCULAR SYSTEM-
Inspection-
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse or pulsations cannot be appreciated
Palpation-
Apical impulse is felt in the fifth intercostal space, 2 cm away from the midclavicular line
No parasternal heave or thrills are felt
Percussion-
Right and left borders of the heart are percussed
Auscultation-
S1 and S2 heard, no added thrills and murmurs are heard
CENTRAL NERVOUS SYSTEM-
HIGHER MENTAL FUNCTIONS:
Patient is Conscious, well oriented to time, place and person.
All cranial nerves - Intact
Motor system
Right. Left
BULK
Upper limbs. N. N
Lower limbs N. N
TONE
Upper limbs. N. N
Lower limbs. N. N
POWER
Upper limbs. 5/5. 5/5
Lower limbs 5/5. 5/5
Superficial reflexes and deep reflexes are present, normal
Gait- Could not elicit, the patient was not able to get off the bed
No involuntary movements
Sensory system- All sensations (pain, touch, temperature, position, vibration sense) are well appreciated
INVESTIGATIONS
The routine investigations done for this patient include,
12/3/22
Complete urine exam-
Albumin- +
Sugar, bile salts, bile pigments- normal
Pus cells- 2-4
Epithelial cells- 2-3
RBC- nil
Casts- nil
Complete blood picture-
Reticulocyte count- 0.5%
Hb- 6.9
TLC- 6600
N/L/E/M- 93/4/1/2
Platelet count- 3
PCV- 22.5
MCV- 64.6
MCH- 19.8
MCHC- 30.6
RDW- CV-19.8
SD-47.5
RBC- 3.48
13/3/22
Sr Iron- 38
Hb- 6.5
TLC- 6500
PCV- 21.6
MCV- 65.6
Platelets- 3
Ret count- 0.6
Absolute reticulocyte count- 0.4
Total iron deficit- 1279
Mentzer index- 19.8
An ECG of the patient was taken
TREATMENT-
12/3/22 1am
On observation, the patient is conscious and coherent.
BP- 110/70mmHg
Temp- 99.2F
PR- 89 bpm
CVS- S1,S2 heard
RS- Bilateral air entry positive
CNS- NAD
P/A- Soft, diffuse tenderness
Treatment-
- NBM until further notice
- Inj PAN 40mg IV OD
- Inj ZOFER 4mg IV BD
- Inj Monocef 1g IV BD
- Inj Metrogel 100ml IV TID
- Inj Tramadol 1amp in 100ml NS IV BD
- Vitals monitoring every 2 hourly
- IVF 20 NS and 10 DNS at 100ml/hr
- Inj oflox TID
13/3/22
On observation, the patient is conscious, coherant, and cooperative
BP- 110/80mmHg
Temp- 98.2F
PR- 67 bpm
CVS- S1,S2 heard
RS- Bilateral air entry positive
CNS- NAD
P/A- Soft, diffuse tenderness
Patient passed flatus, bloating improved, abdominal discomfort improved
Provisional diagnosis acute gastroenteritis and nutritional anaemia which is microcytic hypochromic anemia.
Treatment-
- NBM until further notice
- Inj Iron sucrose 200mg in 100ml NS over 40 min
- Inj PAN 40mg IV OD
- Inj Buscopan IM
- Inj ZOFER 4mg IV BD
- Inj Metrogel 100ml IV TID
- Inj Tramadol 1amp in 100ml NS IV BD
- Vitals monitoring every 2 hourly
- IVF 20 NS and 10 DNS at 100ml/hr
- Inj oflox 200mg IV BD
REFERRALS
SURGERY REFERRAL
(12/03/2022)
Notes include-
On examination, patient was conscious, coherent and cooperative.
After doing a per abdomen examination, the abdomen was noted as being soft, no guarding or rigidity, non tender and bowel sounds were heard.
Findings after a per rectal examination, shows no external skin changes, normal sphincter tone, rectum is collapsed and gloved finger stained by fecal matter.
Provisional diagnosis- Acute gastroenteritis with the possibility of paralytic ileus secondary to an electrolyte imbalance.
Comments
Post a Comment