GENERAL MEDICINE CASE DISCUSSION
68 years old lady with lower abdomen pain & Type II Diabetes
May 14, 2023
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Cheif complaints :
68years old lady who is a resident of nalgonda came with
C/o loose stools 3-4 episodes per day since 1week
C/o pain abdomen since 4days
C/o fever with chills since 4days
C/o vomitings since 3days
C/o abdominal distension since 3days
C/o constipation since 2days
History of presenting illness :
Patient was apparently asymptomatic 1week back then she had c/o loose stools 3-4 episodes per day which lasted for 2days, watery, not a/w blood &mucus ,black coloured ,large volume followed by she had c/o pain abdomen in epigastrc region f/b diffuse colicky type(squeezing) & she also had c/o fever a/w chills which was high grde,intermittent, no evening rise of temperature, a/w vomitings, non bilious, non projectile ,food as content &abdominal distension. She also has c/o constipation since 2days.
Past History :
No history of similar complaints in the past.
K/c/o DM since 10 years on regular medication.
N/k/c/o HTN, Asthma, TB,CVD, CAD, Epilepsy
No past surgical history
No h/o blood transfusions.
Personal History :
Diet -Mixed
Appetite -Normal
Bowel & Bladder -Regular
Sleep -Adequate
No addictions & allergies
Family History :
Not significant
General Examination :
Patient is conscious,coherent, co-operative
thin built &moderately nourished
Pallor-absent
Icterus-Absent
Cynosis-Absent
Clubbing-Absent
Lymphadenopathy -Absent
Pedal Edema -Absent
Vitals @admission
Temp - 98.8F
PR- 116BPM
RR-22CPM
Bp-130/70mmHg
Spo2- 97%
GRBS-221mg/dl.
Systemic Examination
I) Per Abdomen :
INSPECTION :-
Shape of abdomen -Distended
Umbilicus - inverted
No scars, sinuses, straie
No visible pulsations & visible peristalsis
Movements of all 4 quadrants moving equally with respiration
PALPATION :-
All inspectory findings are confirmed
No local rise of temperature
Tenderness present in the epigastric region
No palpable mass present
No palpable lymphadenopathy
No organomegaly
Hernial orificies - Free
PERCUSSION :-
No signs of fluid thrill & shifting dullness
Resonant note heard (except liver dullness)
AUSCULTATION :-
Bowel sounds present
No bruit heard
II) Respiratory system :
Normal vesicular breath sounds heard
Bilateral air entry present
No added sounds
III) CVS:-
S1S2 heard ,No murmurs
IV) CNS :-
NAD, HMF intact
Investigations :-
15/5/23
Hemogram
BGT
CUE
15/5/23
Blood group - O positive
Malarial parasites - Negative
ESR - 8 mm/1st hour
PT - 15sec
INR -1.11
Aptt -31 sec
Reticulocyte count - 0.5%
RBS- 230mg/dl
LDH - 258 IU/L
RFT :-
Blood urea-52mg/dl
sr.creatinine- 2.4 mg/dl
Sodium -135mEq/L
Potassium - 4.1mEq/L
Calcium - 1.06mmol/L
Chloride- 101 mEq/L
Sr.Magnesium - 2mg/dl
LFT :-
TB - 1.37 mg/dl
DB- 0.26mg/dl
AST - 16IU/L
ALP - 15 IU/L
ALP - 497 IU/L
TP - 5.5gm/dl
Albumin - 2.6gm/dl
A/G ratio - 0.92
Serology - Negative
C-reactive protein - positive
16/5/23
Hb - 9.9 gm/dl
TLC - 15,600 cells/cumm
N/L/E/M - 83/10/1/6
PLT - 1.50
16/5/23
RFT :-
Blood urea- 63mg/dl
sr.creatinine- 2.7mg/dl
Sodium -135mEq/L
Potassium - 3.9mEq/L
Calcium - 1.06mmol/L
Chloride- 98mEq/L
17/5/23
Hb - 10.6gm/dl
TLC - 13,700 cells/cumm
N/L/E/M - 70/18/1l2/10
PLT - 1.56
16/5/23
RFT :-
Blood urea- 75mg/dl
sr.creatinine- 2.7mg/dl
Sodium -135mEq/L
Potassium - 4mEq/L
Calcium - 1.06mmol/L
Chloride- 103mEq/L
Urine for ketone bodies - negative
X-ray erect abdomen
ECG
2decho
