A 22 year old male patient with 8-10 episodes of emesis associated with nausea, lower abdominal pain and recurrent fever - GM CASE 18
23rd June 2023
CASE STUDY 18
Hello, I am Saloni .S. Gangotri , a 5th semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.
CASE SHEET:
CHIEF COMPLAINTS:
c/o
- 8-10 episodes of emesis over one night 10 days back accompanied by nausea.
- recurrent fever for 2-3 days 9 days back not exceeding 101°F.
- lower abdominal pain before and after emesis.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 10 days back when he developed nausea and vomited around 8-10 times overnight. It contained food particles, water, was non-bilious and non projectile in nature. This was accompanied by pain in the lower 3 quadrants of the abdomen. He also developed onset of fever which was not high grade reaching around 100-101°F and was relieved on medication. He was taken to the local hospital in Suryapet with the same complaints where he was administered saline and consumed paracetamol 3 times per day for the fever and was discharged. Soon after, the fever relapsed and the vomiting though reduced episodes of around 5-6 times along with nausea was present so he was admitted into the AMC of our hospital. He was prescribed Ondensetron twice a day along with an antibiotic (name unknown) for a 2 day course. On examination it was also found that he had a reduced platelet count and and elevated bilirubin level for which he was prescribed the tablet - Bioliv - 300 twice a day.
-no h/o burning micturition
-no h/o reduced urine output
-h/o itching and rash on both Upper and Lower limbs for which he did not take any medication and healed spontaneously.
-h/o reccurent fever ever since the vomiting episodes began. The fever was not high grade and reduced on medication.
-no h/o cough with sputum.
-no h/o constipation.
-no h/o diarrhea.
-no h/o headache, blurring of vision.
ASSOCIATED DISEASES:
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PAST HISTORY:
No K/C/O HTN, DM, TB, Epilepsy, CAD, CKD.
No h/o blood transfusions.
No surgical history.
PERSONAL HISTORY:
Unmarried.
Resides in Suryapet.
Autodriver by occupation, stopped driving since 2 weeks.
On a mixed diet.
Had reduced sleep earlier during the emesis episodes but now is adequate.
Had a reduced appetite now normal.
Normal Bowel movements.
Has no known allergies.
Has no known addictions. Consumed mild alcoholic beverages occasionally.
FAMILY HISTORY:
- h/o mother having diabetes mellitus since 18 years and is on regular medication. She also has HTN since 5-6 years for which also she is on regular medication.
Has N/K/C/O No Strokes. No CAD, TB, Asthma or Epilepsy.
DRUG HISTORY:
GENERAL EXAMINATION:
-No palor
-Icterus present
-No cyanosis
-No lymphadenopathy
-No pedal edema
-No clubbing of fingers
VITALS:
Temperature: Afebrile - 98.9°F
Pulse: 84 beats per minute
Respiratory rate: —18 cycles per minute
Blood pressure: 120/80 mm of Hg
SPO²: 100%
GRBS: mg%
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 present
Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular? yes
Abdomen:
-Shape : Scaphoid
-No Tenderness present
-No palpable mass
-Non palpable spleen
-Non palpable liver
-No free fluid (ascites) present
-No bruits
-Bowel sounds: heard
Central Nervous System:
Conscious and Alert
Speech: Normal
INVESTIGATIONS:
Biochemical investigations:
ECG:
2D-ECHO REPORT:
ULTRASOUND REPORT:
GRAPHIC SHEET :
PROVISIONAL DIAGNOSIS:
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