1801006084-LONG CASE

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A 30 yr old female resident of Choutuppal daily wage labour by occupation presented to the OPD with chief complaints of generalised weakness since last month , stomach pain from last 4 days and vomiting from the last 2-3 days.

HISTORY OF PRESENTING ILLNESS-

Patient was apparently asymptomatic 1 month ago then she developed fever which was sudden in onset and intermittent and was relived on medication(PCM) not associated with chills and rigirs she also had vomiting which was non blood stained bilious and projectile 2-3 times a day and small volume watery diarrhoea which was non blood stained for 10 days. At that time the patient came to our hospital and diagnosed as acute gastritis and on investigation incidentally found to be having an low heamoglobin of 5g/dl . She was not admitted due to personal reasons and was prescribed oral iron medications. 

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Then few days later she had stomach pain which was diffuse throbbing and intermittent and had no aggravating or relieving factors and also had vomiting which was non projectile occurs after meals non blood stained and bilious and contians digested food as its particles. So she was presented to our hospital on 13/3/2023

Daily Routine-

She wakes up early around 6-00 AM and freshen ups has tea in morning and does all household work and eats rice mainly in her all meals. She is presently not working due to non - farming season.

NUTRITION RECALL 24 Hrs-

7 AM - Tea (105 cal)

8 AM - Rice(2 cups - 427 cal) dal (198 cal)

2 PM - Rice dal

8 PM - Rice dal

 

10 PM - Milk(149 cal)

Total calories 2129 calories per day

PAST HISTORY-

Not a known case of DM/HTN/Asthma/Epilepsy/Tuberculosis/Leprosy/CKD/CAD

PERSONAL HISTORY-

Diet - Mixed 

Appetite - Normal

Bladder movements- Regular

Bowel movements- Regular

Sleep - Adequate

Allergy - No

Addictions - No

MENSTRUAL HISTORY-

Age of menarche - 14 yrs 

Cycles regular 4 day flow with 40 days duration associated with pain and clots

Uses 2 sanitary napkins/day.

Last menstrual period was on 5/3/23.

MARITAL HISTORY-

Marital life - 15 yrs

P2L2

1st child - 2 yrs after marriage male  child (13 yrs old) healthy by LSCS.

No usage of any contraception 

Concieved after 4 yrs.

During 2nd child pregnancy-

History of parentral iron in the 8th month of pregnancy 

History of blood transfusions in the 9th month of pregnancy.

2nd child - Lscs male (9 yrs old ) healthy.

Then tubectomy was done.

FAMILY HISTORY -

Mother is a known case of hypertension and on medication since 10 yrs.

GENERAL EXAMINATION-

Consent is taken and patient us examined in a well lit room with adequate ventilation with a female attendant and she is conscious coherent and co operative well oriented to time place and person.

Pallor - Present 

Icterus - Absent

Cyanosis - Absent

Clubbing - Absent

Lymphadenopathy - Absent

Pedal Edmea - Absent

Oral iron medications

VITALS -

Pulse Rate - 67 beats per minute which is regualr in rhythm normal volume and there is no radioradial and radiofemoral delay

Blood Pressure - 110/80 mm Hg in right arm sitting position 

Respiratory Rate - 14 counts per minute 

Temperature - 38.8 C

SYSTEMIC EXAMINATION-

Abdomen Examination-

Inspection - 

Shape - Round with no distension

Umbilicus - Inverted 

LSCS scar in lower abdomen

No visible discharging sinuses ,swellings ,dilated veins , peristalsis or pulsations .

Hernial orifices are free.

Palpation -

No local rise of temperature

Tenderness present which is diffuse over left upper quadrant, left lumbar, umbilicus and hypogastric regions.

No hepatomegaly

No splenomegaly

PERCUSSION-

Fluid thrill and shifting dullness absent.

Auscultation-

Bowel sounds present

CVS - 

Inspection-

No visible apical impulse

No other sinuses scars or dilated veins and pulsations.

Palpation-

Apex beat was localized in the 5 th ICS 2cm medial to mid claviclular line

No thrills or parasternal heaves.

Auscultation-

S1 and S2 heard

No murmurs

Respiratory Examination-

Inspection-

Chest appears bilaterally symmetrical

Respiratory movements appear equal on both sides

Trachea central in position

Palpation-

Trachea is central

Auscultation-

B/l air entry

No vesicular breath sounds

CNS-

Higher Mental Functions - Normal

Memory- Intact

Cranial Nerve Examination- Normal

Motor Examination-

Normal tone and power in both upper and lower limbs(5/5)

Reflexes - 

Superficial- Corneal conjuctival and plantar reflexes present on both sides 

Deep - 

                   Rt         Lt

Biceps       2+        2+

Triceps     2+        2+

Knee         3+        3+

Ankle       1+         1+

Sensory Examination -

Fine touch vibration and joint sense is intact on both sides.

Pain and temperature intact on both sides 

Cerbellar functions - Normal

No signs of meningeal irritation.

PROVISIONAL DIAGNOSIS-

Iron deficiency Anaemia

INVESTIGATIONS-

Hemogram -

Day 1 - 13/3 -

Hemoglobin levels - 10.5 gm/dl (12-15 gm/dl)

Total WBC count - 13,400 ( 4000- 10000)

MCV - 72.7 (83-101)

MCH - 19    (27-32)

MCHC - 27.2 (31.5 - 34.5)

RBC count - 

Perioheral smear - Microcytic hypochromic anemia with few normocytes microcytes macrocytes and pencil cells and leucocytosis.

Day 2 - 14/3 -

Hemoglobin levels - 9.1 (12-15)

PCV - 33.6 (35-46)

MCV - 72.9 (83-100)

MCH - 19.7 (27-32)

MCHC - 27.1 (31.5 - 34.6)

Day 3 - 15/3-

Hemoglobin- 8.8 (12-15)

PCV - 32.4 (36-46)

MCV - 75.2 (83-101)

MCH - 20.4 (27-32)

MCHC - 27.2 (31.5 - 34.5)

Day 4- 16/3

Hemoglobin -8.8

PCV-32.3

Total leucocyte count-6500

RBC-4.24

Day 5-17/3

Hemoglobin -8.9

PCV-32.9

Total leucocyte count-8500

Electrolytes-

Day 1 - 13/3

Pottasium - 5.4 mEq/L ( 3.5 - 4.5)

Sodium chloride and calcium normal levels

Day 2 - 14/3

Pottasium - 4.1 ( in normal range 3.5-4.5)

Serum creatinine - 0.6 mg/dl (0.6 -1.1)

Blood urea - 26 mg/dl (12-42)

Retic count - 1.5%

Serum iron - 38 microg/dl (37-145)

Day 3-15/3

Serum creatinine-0.6

Potassium -4.1

Day 5-16/3

Blood urea-20

ECG -

X-ray

USG -

Right small kidney - 5.6*2.9cm

Left kidney - 10.5*4.8 cm

Plan of care -

IV fluids NS 75 ml/hr

Inj pan 40mg/IV/OD

Inj zofer 4mg/IV

Tab PCM 650 mg OD

Syp sucralfate 10 ml/TID

Syp cremaffin citrate 15 ml

Inj vitkofol 1000 microgram/IM/OD

Tab orofer