GENERAL MEDICINE CASE DISCUSSION
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THE CASE :
A 28 year old female resident of Nalgonda came to the medicine department with the chief complaints of nausea and vomiting since last 3 days.
History of presenting illness :
The patient was apparently asymptomatic 3 days ago. Then she had episodes of vomiting and loose stools.
Vomiting : sudden in onset , non billious , non projectile, with burning type of pain abdomen and with clear contents with the frequency of every 10 minutes.
Loose stools : sudden in onset , watery in consistency and not associated with mucus or blood with the frequency of every 10 minutes.
There is no history of :
Fever,
Dysphagia,
Abdominal distension,
Haematemesis,
Pedal edema.
Past History:
The patient similar episode 1 year back.
She is not a known case of Diabetes Mellitus , Hypertension, Bronchial asthma.
Family History:
No significant family history.
Personal history:
Diet : Mixed
Appetite : Normal
Bowel and bladder movements : Regular
Sleep - Adequate
No addictions
General Examination:
The patient conscious, coherent, cooperative and moderately built and is comfortably lying on the bed.
Pallor : Present
Icterus : Absent
Cyanosis : Absent
Koilonychia : Absent
Lymphadenopathy : Absent
Edema : Absent
VITALS :
Temperature : Afebrile
Pulse rate : 86 beats per minute
Respiratory rate : 18 cycles per minute
Blood Pressure : 110/70 mm of Hg.
Systemic Examination :
GASTROINTESTINAL SYSTEM :
A) Upper gastrointestinal tract :
Lips : Dry
Teeth : Normal
Gums : Normal
Tongue : Dry
Tonsils : Normal
Palate : Normal
Breath : No foul smell
B) Examination of the Abdomen :
I. Inspection : The legs of the patient are in extended position.
1. Shape of the Abdomen: Scaphoid
2. Flanks : not full
3. Venous prominence : Absent
4. Umbilicus : central in position, no discoloration
5. Skin : Absence of ulcer , striae , pigmentation,
Lower segment cesarean section scar present.
6. No localised swelling
7. Movement of the abdomen : quadrants moving with respiration, no pulsations or visible peristalsis.
II. Palpation:
1. Superficial :
a) Surface temperature : no local rise
b) Tenderness : Absent
c) Consistency : Normal elastic
d) Localised lump : Absent
e) Pulsations : Absent
f) Fluid thrill : Absent
2. Deep :
a) Liver : not palpable
b) Spleen : not palpable
c) Kidneys : not palpable
d) Rebound tenderness : Absent
e) Abdominal mass : Absent
III. Percussion :
1. General note of the abdomen : Present
2. No liver of splenic dullness
3. No shifting dullness
IV. Auscultation :
1) Bowel sounds heard
2) Hepatic or splenic rub : Absent
3) Bruit : Absent
RESPIRATORY SYSTEM:
1 . Position of trachea : Central
2. Normal vesicular breath sounds
3. No crepitation or Ronchi
CARDIOVASCULAR SYSTEM:
Normal S1 and S2 heard
No murmurs heard
CENTRAL NERVOUS SYSTEM:
1) Higher mental functions : Intact
2) Cranial nerves : Intact
3) Motor system : Normal
4) Sensory system : Normal
5) Reflexes : Intact
6) Cerebellar functions : Intact
Provisional Diagnosis :
Acute Gastroenteritis
Differential diagnosis :
Hepatitis
Peptic ulcer
Investigations:
Complete blood picture
Complete urine examination
Chest X-ray
ECG
Ultrasound
Treatment :
Intravenous fluids : Normal saline, Ringer lactate
Injection PANTOPRAZOLE ( proton pump inhibitor)
Injection ZOFER ( Ondansetron - antiemetic)
Injection METROGYL ( Metronidazole )
Injection MONOCEF ( antibiotic)
Tablet DOXYCYCLINE 100 mg/ 3 tablets
Oral Rehydration Solution sachet in 1 litre of water.
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