24 yr old female with complaints of Pain abdomen,loose stools with blood and low grade fever and vaginal discharge

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. 


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 patient's clinical problems with collective current best evidence based inputs. 


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

Here is a case i have seen:

A 24year old women  presented to our casuality at 10 :30 am on 21-11-20 with complaints of 

Pain abdomen since 10 days 

Vaginal discharge (curdy white)since 20 days  

Low grade fever since 10 days 

Vomting since 2 days 

Loose stools with blood since 10 days 

( first 4-5days : 6-7 episode/ day 

Past 5 days : 3-4 episodes : water in consistency ; mixed with frank blood ;no pain per rectum /no mass per rectum 

H/o unable to pass  flatus + 

Loose stools occur following food intake and pain abdomen 

No h/o passage of worms 

No h/o outside food intake 

H/o non veg intake + ( 2 days prior to onset of diarrhoea ) 


 HISTORY OF PRESENT ILLNESS

- c/o pain abdomen , colicky type in umbilicus , hypogastrium , left hypochondrium , left lumbar area . Intermittent type of pain , 

Nausea+ 

Loss of appetite + 

Fatigue + 

H/o fever - low grade @ night times 

Vaginal discharge is curdy white, foul smelling,associated with itching.

c/o vomiting since 2 days - 2 episodes/ day contains food  , no black vomitus , non projectile 

C/o decreased urine output and burning micturition

Assoc with generalised weakness , palpitations and giddiness + 

No h/o cough and chest pain 

PAST HISTORY

No h/o similar complaints in the past

Not a k/c/o DM/HTN/TB/Asthma/Epilepsy/Thyroid/cardiovascular abnormalities

Tx/ h/0 : Pt was advised oflox 2 outside 

                2 LSCS 

Menstrual History

Age of menarche:13yrs

5/30 cycle

No clots and dysmenorrhoea

Vitals

Temp - 98.2 

Pulse - 110/ min 

Bp-90/60mmhg

Rr-18cpm

Per Abdomen - tenderness at umbilicus , hypogastrium 

Cvs - s1 and s2 + ,no murmurs

Palor present



Cbp

cue

Lft

Rft

Serum electrolytes
reticulocyte count
stool for occult blood
Hemogram
usg abdomen


Diagnosis

Amoebic dysentery with vaginal candidiasis with iron deficiency anaemia.

TREATMENT 

Day 1  

1.Plenty of oral fluids 2-3L/day

2.ors sachets in 1 lit of water drink 200ml after each loose stool 

3.soft oral diet

4.Inj.ciprofloxacin 500mg/Iv/Bd

5.Inj.Metrogyl 100ml/Iv/tid

6.Inj.Pan 40mg/Iv/od

7.inj.zofer 4mg/iv/tid

8.Inj.optineuron1amp in 100ml Ns/iv/od

9.T.Dolo 500mg/po/bd

10.Inj.Buscopan /IM/sos

11.Ivf Rl 2 units Dns 2 units @75ml/hr

12.T.sporolac Ds Tid 

13.Candid V6 vaginal pessary

Day 2

C/o 2 episodes of loose stools since last night 1 episode and blood tinged loose stool yesterday morning,pain abdomen.nausea present

1.Plenty of oral fluids 2-3L/day

2.ors sachets in 1 lit of water drink 200ml after each loose stool 

3.soft oral diet

4.Inj.ciprofloxacin 500mg/Iv/Bd

5.Inj.Metrogyl 100ml/Iv/tid

6.Inj.Pan 40mg/Iv/od

7.inj.zofer 4mg/iv/tid

8.Inj.optineuron1amp in 100ml Ns/iv/od

9.T.Dolo 500mg/po/bd

10.Inj.Buscopan /IM/sos

11.Ivf Rl 2 units Dns 2 units @75ml/hr

12.T.sporolac Ds Tid

13.Candid V6 vaginal pessary

Day 3

C/O 2 episodes of normal consistency stools since yesterday morning

No fever spikes

1.Plenty of oral fluids 2-3L/day

2.ors sachets in 1 lit of water drink 200ml after each loose stool 

3.soft oral diet

4.Inj.ciprofloxacin 500mg/Iv/Bd

5.Inj.Metrogyl 100ml/Iv/tid

6.Inj.Pan 40mg/Iv/od

7.inj.zofer 4mg/iv/tid

8.Inj.optineuron1amp in 100ml Ns/iv/od

9.T.Dolo 500mg/po/bd

10.Inj.Buscopan /IM/sos

11.Ivf Rl 2 units Dns 2 units @75ml/hr

12.T.sporolac Ds Tid

13.Candid V6 vaginal pessary





Popular posts from this blog

BIMONTHLY ASSESSMENT (JANUARY)

Image
26 year old woman with complaints of altered sensorium since 1 day,headache since 8 days,fever and vomitings since 4 days More here:  https://harikachindam7. blogspot.com/2020/12/26-year- old-female-with-complaints-of. html Case presentation  links:  https://youtu.be/fz9Jssoc-mA https://youtu.be/d4lLX04oL8s https://youtu.be/CSCxw2zp7Oc a). What is the problem representation of this patient and what is the anatomical localization for her current problem based on the clinical findings? presented to casualty in a state of altered sensorium & irrelevant talk History of B/L hand small joint pains 6 yrs back Multiple joint pains 3 yrs back and diagnosed as SLE  and using treatment which she stopped 10 days ago. C/o headache since 1 month which increased in last 10 - 15 days associated with vomitings since 1 week and fever, neck pain , generalized weakness since 4 days and altered sensorium with irrelevant talk since 1 day. Anatomical localization: Headache,neckpain, fe...
Read more

22 yr old man with difficulty in walking and sitting without support since 2 months....

Image
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.  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 patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome. Here is a case i have seen: 22 year old man from Singaram presented with the complaints of Difficulty to walk without support since 2 month Difficulty to sit without support since 2 months He was born out of a non consanguineous marriage. His father works as a coolie at Singaram village. He is third in  birth order. He has an elder brother and sister who are married. He was delivered through normal vaginal delivery at home by a local RMP practitioner. He did not cry imm...
Read more

medicine assignment

Image
1) A 55 year old man with Recurrent Focal Seizures Detailed patient case report here:  http://ushaindurthi. blogspot.com/2020/11/55-year- old-male-with-complaints-of. html 1. What is the problem representation of this patient and what could be the anatomical site of lesion ? 55 yr old male who is k/c/o diabetic and chronic alcoholic with right upper limb weakness and involuntry movements of right upper and lower limbs, Internal capsule: pure motor strokes, ataxic hemiparesis, and clumsy hand-dysarthria.  Frontal lobe: urinary incontinence, and head and eye deviatiation Temporal lobe: It is preceeded by aura. Aura could be  sensory, emotional, cognitive, or autonomic features prior to onset of impaired awareness. Postictal confusion typically occurs. 2. Why are subcortical internal capsular infarcts more common that cortical infarcts?  Subcortical areas are supplied by penetrating branches,Occlusion of these penetrating arteries result in subcortical ...
Read more