Case history 8

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Date of Admission- 20-12-21 

A 40 year old female presented to OPD with chief complaints of abdominal pain , vomitings 10 episodes at night and loose stools of 4 episodes at night since 2 days. 

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 2 days back i.e till 19-21-21 , then on 20-12-21 she developed pain in the lower abdomen colicky in nature. Initially radiating from loin  to groin then non radiating pain confined to lower abdomen. She had vomitings of 10 episodes non projectile , non bilious and with food as its contents and loose stools of 4 episodes on 21-12-21 .

HISTORY OF PAST ILLNESS 

Patient has a history of Intestinal obstruction 5 years ago . Exploratory laparoscopy and emergency adhesiolysis was done .

Patient has a history of Hernioplasty 17 years ago ,  Hysterectomy 15 years ago and LSCS ( lower Segment caesarean section ) 21 years ago . 

No history of , asthma, TB, CAD, epilepsy.

PERSONAL HISTORY

  appetite - Decreased 

Bowel movement is regular . Loose stools since 1 day . 

Burning Micturition

Menstrual history - Regular 

Addictions- None 

Sleep  - Regular 

FAMILY HISTORY

         No history of DM, CAD, Asthma and thyroid disorders in the family

GENRAL EXAMINATION 

Patient is conscious, coherent, co-operative.

There are no signs of icterus, clubbing, pallor, cynosis, lymphadenopathy

VITALS

Temperature- afebrile 

Pulse rate-  78 bpm

Respiratory rate - 19cpm 

BP- 110/70 mm Hg

Spo2-  99%

GRBS -80mg/dl

SYSTEMIC EXAMINATION:

Cardiovascular System

Cardiac sounds- S1, S2  are heard

RESPIRATORY SYSTEM

Position of trachea- central

Breath sounds- vesicular

Adventitious sounds- No

 

ABDOMEN

Mild tenderness in hypogastrium  . 

Blumberg sign - positive 

Previous laparoscopy scar is seen

Palpable mass- None 

Free fluid- none 

Liver- Not palpable

Spleen- Not palpable

Bowel sound- Yes

CENTRAL NERVOUS SYSTEM 

Patient is conscious 

Speech- normal

No sign of meningitis 

Motor and sensory system- Normal

Cranial nerves- intact

Investigation 

On 21-12-21 

X Ray Abdomen 

USG abdomen and pelvis -  Multiple dilated bowel loops in the abdomen , largest being 3cm with sluggish peristalsis . 

Urinary bladder - empty 

 

Hemogram : Hb - 15.9 gm/dl

  Total cell count -10,800 cells / cubic mm

Neutrophils-90 % 

MCV -78.7 

MCHC - 35.6 

Serum electrolyte 

Creatinine - 0.9 

Na +  145 mEq/L

K+ 4.6 mEq/L

Cl 98 mEq/L

Provisional diagnosis- Acute gastroenteritis

Differential Diagnosis- Inflammatory bowel syndrome 

Malabsorption syndrome 

TREATMENT

On 20-12-21 

IV Pan 40 mg OD

IV Metrogyl TID

Tab Sporolac OD 

Inj buscopan IV OD 

On 21 -12-21

IV Pan 40 mg OD

Inj Zofer 4mg IV TID 

IV Metrogyl TID

Tab Sporolac OD 

Inj buscopan IV OD 

Inj . monocef IV BD