Case presentation 10
20.12.21
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Chief complaint:
A 40 year old female presented to OPD with chief complaints of radiating pain in Lower abdomen colicky type and vomitings,loose stools.
History of present illness:
Patient was apparently asymptomatic 7 years ago .In 2016,she had fever,chills and constipation abdominal pain and was diagnosed intestinal obstruction and got surgery done in kims.recently she is having similar symptoms since 2 days i.e 18.12 21.she developed pain in the lower abdomen of radiating type of sudden onset on 18.12.21 around 1 AM and then she was taken to nalgonda hospital and took medicine and injection..but the pain did not subsided and then she was taken to KIMS on 19 th morning.she was referred to surgery department but after investigations (ultrasound and erect abdominal x ray) there was no intestinal obstruction and went home after taking medication...but late night she had non bilious,non projectile vomitings of 10 episodes and 4 episodes of loose stools and was admitted to OPD next morning.
Daily routine
Pt wakes up at 5 o clock and takes breakfast at 10 0 clock and lunch at 1:30pm and at 8 pm she takes dinner.she leads a very normal and happy life and serves her family.
On 18th as usual she had breakfast lunch and had chicken for dinner.around 12 am she developed pain in Lower abdomen and severity increased and around 1 am she was taken to nalgonda govt hospital.
Past history:
History of intestinal obstruction 5 years ago Exploratory laparotomy,and adhesiolysis
Hysterectomy 15 years back.
Hernioplasty 17 years ago.
Personal history:
She takes mixed diet with loss of appetite due to vomitings and abdominal pain.her sleep cycle is also disturbed.
She consumes toddy occasionally.
No history menstrual cycle since 15 years (hysterectomy)
General examination:
Patient is conscious, coherent, cooperative.
No pallor, icterus, clubbing, lymphadenopathy, edema
Vitals:
Temp: afebrile
Pr: 98 bpm
Rr: 15 cpm
Bp: 110/70 mm hg
SPO2: 98%
Systematic examination:
CVS: S1 and S2 heard
P/A: soft , tender ,laporotomy scar is visible.
CNS: NAD
RS : bilateral air entry is positive
Provisional diagnosis: acute gastro enteritis.
Investigations:
Biochemistry
Serum Electrolyte:
Na -145 mEq/L (136-145)
K -3.9 mEq/L (3.5-5.1)
Cl -96 mEq/L (98-107)
Serum creatinine:
0.9 mg/dl (0.9-1.3)
Blood urea :
46 mg/ dl(12-42)
Blood investigations:
HB 15.9gm /dl(13-17)
Total count 10,800 cell/cumm(4000-10000)
Neutrophils 90 %(40-80)
Lymphocyte 05%(20-40)
MCV 78.7(83-101)
MCHC 35.6(31.5-34)
RBC count 5.68 millions per cumm( 4.5 -5.5)
Liver function tests
Total bilirubin 1.46mg/dl(0-1)
Direct bilirubin 0.37mg/dl(0.0-0.2)
SGOT 52(8 to 45)
SGPT 36(7 to 56)
Alkaline phosphatase 169(58-123)
Erect spine x ray:
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