60 year old female with loose stools and vomiting

FINAL PRACTICAL EXAMINATION SHORT CASE
Hall ticket number:1701006196

Chief complaints:
A 60 year old female labourer by occupation came with chief complaints of loose stools since 15 days, vomitings since 10 days.

History of presenting illness:

Patient was apparently asymptomatic 15 days back then she developed loose stools which was 8-10 episodes initially and  since 4 days decreased to 4-5 episodes per day associated with abdominal pain in upper quadrant colicky in nature non radiating
Vomitings was of 2 episodes previously non bilious non.

Past history:

No history of similar complaints in past
No history of diabetis mellitus, hypertension, asthma, Tuberculosis,CAD.

Personal history::

Diet :mixed
Appetite:normal
Sleep:Adequate
Bowel and bladder: normal
Addictions: occasionally toddy 
 
Treatment history:: insignificant

Surgical history: hysterectomy done 10 yrs back

General examination:

On taking prior consent patient was examined in a well lit room and patient is moderately built and moderately nourished

Patient was conscious coherent cooperative
Well oriented to time place person
Moderately nourished and built

No pallor,icterus,cyanosis, clubbing,lymphadenopathy,edema

Vitals:
Temperature: afebrile
Pulse:82bpm
Respiratory rate:16cpm
Bp:110/80mmof Hg

Systemic examination:

Per abdomen:

Inspection.

Shape of abdomen-scaphoid
Umbilicus-inverted,central located
No sinuses or scars on abdomen

Palpation:

No rise in temperature
Tenderness present over upper quadrant epigastric 
No palpable mass 
No free fluid
Liver palpable
Spleen not palpable

Percussion:

Dull note on right upper quadrant
No fluid thrill
No shifting dullness

Auscultation:

Bowel sound heard

Respiratory system:

B/L symmetrical elliptical
Trachea central
No sinuses ,scars

Tactile vocal fermitus-equal normal on both sides
Normal vesicular breath sounds heard

Cardio vascular system::
S1S2 heard
No murmurs

Central nervous system:
Speech normal
Cranial nerves normal
Sensory and motor system: intact
Reflexes.normal

Investigations:

Complete blood picture:

Hemoglobin:12.2gm/dl
Total leucocyte count:5500cels/mm3
Neutrophils:70 %
Lymphocytes:20%
Monocytes:04%
Eosinophils:06%
Basophils:0
Platelet count:2L/mm3

Random blood sugar:102mg/dl

Blood urea 42mg/dl

Serum electrolytes:

Na+=137
K+=2.5
Cl-=102

Serum creatinine-1.2mg/dl

Liver function tests:
 
Total bilirubin:0.91 mg/dl
Direct bilirubin:0.18 mg/dl
AST:41IU/L
ALT:43IU/L
ALP:154IU/L
Total protiens:7gm/dl
Albumin:3.8gm/dl
Smear: normocytic normochromic

HIV RAPID TEST : POSITIVE

Provisional diagnosis:

Gastroenteritis

Treatment:
Iv Fluids
Inj.zofer
Tab.sporolac
Cap radotril
Inj.pan 40
Inj.kcl 1amp in 500ml Ns

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