45yr old female with c/o pain abdomen,loose stools,fever since 5days

ROHITH SOMANI

Roll no.147

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I’ve 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.

CASE DISCUSSION:

Patient came to casualty with C/o loose stools,pain abdomen,fever since 5days

HOPI:

-patient was apparently alright 5days ago.she developed high grade fever with chills,intermittent type,temporarily relieved on medication associated with loose watery stools 3to4 episodes per day,non blood stained,non foul smelling with diffuse pain abdomen which is insidious in onset, conscious in nature, dragging type of pain.

No c/o vomiting, burning micturition,cold,cough,sob,chest pain, palpitations, orthopnoea,PND

PAST HISTORY

N/k/c/o DM,HTN,CVA,CAD,TB,Asthma

No h/o similar complaints in the past

History of hysterectomy

PERSONAL HISTORY

Appetite-normal

Diet-mixed

Bowel and bladder - increased frequency of stools per day

Sleep-adequate

No history of allergy to food or drugs

GENERAL EXAMINATION

Patient is conscious, coherent, coperative. Moderately built moderately nourished

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

Vitals: 

temperature:98.5°F

Pulse rate:78bpm

Resp rate:18cpm

BP:100/70mmhg

Spo2:98%

SYSTEMIC EXAMINATION

cvs

S1S2 heard

No cardiac murmurs

Apex beat heard at 5th ICS

Respiratory system

Normal vesicular breath sounds heard

Position of trachea - central

Abdomen

Inspection: shape-scaphoid

Umbilicus - central and inverted

Scar is seen below umbilicus,no engorged veins

All abdominal quadrants moving equally on inspiration and expiration.

Palpation:  diffuse tenderness present

Liver and spleen not palpable

Percussion: resonant note heard all over abdomen on percussion

Auscultation: bowel sounds are heard on auscultation

CNS

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 3/5

Reflexes: Right. Left. 

Biceps. ++. ++

Triceps. ++. ++

Supinator ++. ++

Knee. ++. ++

Ankle ++. ++

Investigation:

USG abdomen-

-hepatic cyst in 7th segment

-right renal calculus(3-4mm)

-bilateral pleural effusion with consolidatory changes underlying collapse in the left lung

-thickened and edematous bowel loops in right iliac fossa

Serology-negative

RBS- 90mg/dl

BGT-O+VE

HEMOGRAM

Hb-10

TLC-5,350

MCH-29.2

MCV-86.5

RBC-3.42

N/L/M/E-4.2/0.5/0.5/0

PLT-83,000

RFT

S.creat-0.6

Urea-17

Na+138

K+3.3

Cl-103

Ca+2-1.18

LFT

TB-1.09.          

DB-0.21

AST-47

ALT-16

ALP-82

TP-3.4

Alb-1.94

A/G:1.33

CUE

Alb+

Sugar-nil

Pus cells-3-4

Epithelial cells-2-3

APTT-31Sec

PT-15Sec

INR-1.11

WIDAL TEST-Negative

SPOT UPCR

Protein-12.2

Creatine-63

Ratio-0.19

Provisional diagnosis 

Atypical typhoid fever

Treatment:

Inj.ceftriaxone 2gm iv/bd

Inj.metrogyl 500mg iv/tid

Inj.pan 40mg iv/bd

4hrly vitals monitoring