21 years old female with vomiting and loose stools

With UG learning is coming to ve almost there to graduate the new case presented to OPD with complaints of vomitings and loose stools

M Bhuvana phanindra, 

9th semister, Roll no.74.

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome

As a part of "patient clinical data analysis" I was given this case to improve my clinical competence in reading and comprehending along with history taking , clinical findings, and investigations , investigations to come up with a  diagnosis .

This is the reflection of my case study:

21 year old female who is MBA student resident of Nalgonda came with chief complaints of Vomitings since 3 days and loose motions since 3 days

History of Present illness:

.Patient was apparently asymptomatic 3 days back .

.On Sunday , she attended a religious meet in a Church where she had Buttermilk and Chicken for the lunch.After going back to her hostel she developed mild fever and headache. In the evening she had curd rice .

.At 2.00 AM in the night ,she had two episodes of vomiting and 4 episodes of loose stools. The vomiting was non-bilious ,non-projectile ,not blood stained and was containing food particles .

.Stools were watery and not blood stained .She was then taken to a private hospital where she was given some medication ( tablets).

.Even then , diarrhoea was not relieved ,so she was admitted to a nearby Government hospital .

.Unsatisfied by their treatment ,she moved to our hospital on tuesday .At our hospital ,she was started on IV fluids and Antibiotics.

Past history:

.No history of similar complaints and hospitalization in the past

.No history of Epilepsy , Asthma ,Thyroid 

Family history : 

.Not significant

Personal history:

.Mixed diet

.Normal appetite 

.Sleep Adequate

.Bowel and bladder -Regular

.No known Allergies to any medication or foods

General Physical Examination

.Examination was done with consent, along with female attendent in a well lit closed room exposed over trunk .

.She was conscious ,coherent and cooperative and well oriented to time ,place ,person.

.Thin built and moderately nourished

.Weight :41 kg

.Height:160 cm

VITALS

.BP :130/80 mm Hg

.HR: 109 bpm

.RR:18 cpm

.Temperature:Afebrile

.Spo2: 100% on room air

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

Head to toe examination:

Clinical images:

Sunken eyes 

Loss of Skin turgidity

Dry mucous membranes

Local Examination:

Inspection :Normal, no scars and sinuses

Palpation :Normal, visual inspectory findings confirmed

Auscultation : Normal ,no crepts or thrills.

Systemic examination:

CVS- S1, S2 heard

RS- B/LAE +

CNS- NFD

P/A- soft

Differential Diagnosis:

Acute Gastroenteritis

Treatment:

1. Inj IV Oflaxacin 200mg BD

2. Inj IV Metrogyl 100ml TID

3.ORS sachet in 1litre water, 200ml after passing each stool.

4. Tab sporolac TID