1801006056 - LONG CASE

 March /16 / 23

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.                                                                                     

I have 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

Blog by Janhavi Virani 

1801006056

A 34 year old female patient who is a farmer by occupation and is resident of choutuppal came to opd with chief complaints of - 

1. Vomitings since 3 days 

2. Abdominal pain since 3 days 

HISTORY OF PRESENTING ILLNESS - 

Patient complains of vomiting since 3 days which contains food  particles ( occurring after intake of food ) 3-4 episodes in a day , yellowish in colour non projectile and non bloodstained . 

History of abdominal pain since 3 days which she describes as diffuse and intermittent associated with nausea , throbbing type aggravated with eating. 

Along with vomiting and abdominal pain patient also has generalised weakness affecting her daily activities. 

Patient was apparently asymptomatic 1 month back then she developed fever which was sudden in onset associated with chills and rigor  , she also had 2-3 episodes of vomiting with pain in abdomen and watery , small volume, non blood stained loose stools . After which patient went to hospital and was diagnosed with anemia with Hb of 5.2gm% . She was advised admission in the hospital to which she refused and was started on oral iron therapy. She also ate iron rich food at home . 

No history of burning micturition, urgency , increased frequency, Dyspnea , paroxysmal nocturnal dyspnea or any bleeding manifestations. 

DAILY ROUTINE- 

Patient wakes up at 6 am and does her daily morning activities then she has her breakfast at 9 am . She packs her lunch and leaves for work ( farmer ) where she has her lunch at 1 pm . She comes back home by 6 in the evening and does household chores has her dinner at 8 pm and sleeps by 9 pm . 

Now because of weakness she is unable to do her daily work . 

MENSTRUAL HISTORY- 

Menarche at the age of 14 years 

Cycles - 5/30 regular ( delayed by 5 days ) 

Usage of cloth 

Associated with dysmenorrhea and presence of clots . 

MARITAL HISTORY - 

She was married at the age of 16 years 

Non consanguineous marriage. 

OBSTETRIC HISTORY- 

She has 2 kinds 

LSCS w as done in both the pregnancies. While 2nd pregnancy patient has history of blood transfusion . 

PAST HISTORY- 

No similar complaints in past 

Patient is not a known case of Diabetes Mellitus , Hypertension, Epilepsy, CAD or any thyroid abnormality. 

DRUG HISTORY- 

Intake of 1. Iron and folic acid tablets since 1 month 

2. Omeprazole and Domperidone tablets 

3. Sefexim 200 mg tablet 

4. Vitamin supplements 

FAMILY HISTORY-

No significant family history 

PERSONAL HISTORY- 

Diet - mixed 

Appetite - normal 

Bowel and bladder- regular 

Sleep - adequate 

No addictions 

GENERAL EXAMINATION- 

Patient is conscious coherent and cooperative 

Moderately built and nourished 

Pallor- ++

Icterus - absent 

Cyanosis- absent 

Clubbing- absent 

Lymphadenopathy- absent 

Edema- absent 

VITALS - 

Temperature- a febrile 

BP - 110/70 mm of hg 

Pulse rate - 65 bpm

Respiratory rate - 17 cpm

SYSTEMIC EXAMINATION- 

ABDOMEN EXAMINATION- 

INSPECTION- 

Shape - round large with no distension 

Umbilicus - inverted 

Equal symmetrical movements in all quadrants with respiration 

No visible pulsations , palpations , dilated veins or localised swelling 

LSCS scar present in lower abdomen, hyperpigmented 

Hernial orifices are free

PALPITATION - 

No local rise of temperature 

Diffuse tenderness ( present in left lumbar , umbilical, hypo gastric areas) 

Deep palpitations- 

No organometaly 

PERCUSSION- liver dullness heard at 5th intercostal space 

AUSCULTATION- 

Bowel sounds present 

No bruit heard 

Cardiovascular system-   

JVP - not raised 

Visible pulsations: absent 

Apical impulse : left 5th intercostal space in midclavicular line.

Thrills -absent 

S1, S2 - heart sounds heard 

Pericardial rub - absent

Respiratory System- 

Patient examined in sitting position

Inspection:-

oral cavity- Normal ,nose- normal ,pharynx-normal 

Shape of chest - normal

Chest movements : bilaterally symmetrically reduced

Trachea is central in position.

Palpation:-

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 5th ICS, 

Chest movements bilaterally symmetrical 

AUSCULTATION 

BAE+,  NVBS

Central Nervous System- 

Higher mental functions intact 

No focal neurological deficit’s present 

 

PROVISIONAL DIAGNOSIS- 

ACUTE GASTRITIS WITH ANEMIA 

INVESTIGATIONS -

1. Hemogram 

2.  Peripheral smear - 

RBC - predominantly microcytic hypochromic with few macrocytes , pencil forms

WBC- increased count on the smear

PLATELETS- adequate 

3. Reticulocyte count - 1.8%

4. Stool for occult blood - negative 

5. Chest X-ray - 

6. ECG - 

7. Blood urea - 25 mg/dl 

8. Serum creatinine- 0.6 mg/ dl

9. USG - 

10. Serum electrolytes- 

Sodium - 141 mEq/dl

Potassium- 5.4 mEq/dl

Chloride - 1010 mEq/dl

DIAGNOSIS:- 

ACUTE GASTRITIS WITH NUTRITIONAL ANEMIA 

SHOWING ASYMMETRIC KIDNEY ON USG

TREATMENT- 

IV fluids ns 75ml/hr 

INJ pan 40 mg/ IV /od 

INJ Zofer 4mg/IV 

INJ optineuron 1 amp in 500ml  ns/ IV/od 

T.PCM 650 mg   od 

Syp.Sucralfate 10ml/tid 

Syp. Cremaffin citrate 15ml 

INJ vitkofol 1000mcg/IM/od 

T.orofer xt/po/od