A 55 year old female patient with Shock, Metabolic Acidosis and Acute Gastroenteritis. - GM CASE 13
7th June 2023
CASE STUDY 13
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
- Pain in middle right side of the abdomen since 2 days.
- acute SOB even at rest since 1 day.
- 6- 8 episodes of vomiting since 2 days.
- 8-10 episodes of loose stools since 2 days.
- high grade fever since 2 days.
- reduced urine output since 1 day.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 days ago until she developed pain in the middle- right side of the abdomen i.e in the right flank which was sudden in onset, gradually progressive, continuous, non radiating in nature, squeezing type which was not relieved on medication. She also complained of shortness of breath even at rest since 1 day. She also complained of 3-4 episodes of watery and foul smelling diarrhea with no traces of blood 2 days ago and 10 episodes on the next day. She had 5-6 episodes of vomiting 2 days ago and 8 episodes on the next day. It was non projectile, not bilious and contained food contents in the 1st episode and the rest were watery. She was administered saline (0.95% NaCl) 1500mL on 7th June out of which she excreted 500mL in urine.
h/o reduced urine output since 1 day.
h/o high grade fever since 2 days which was insidious, continuous and relieved on medication.
h/o SOB on exertion since 10 years but developed SOB even on rest since 1 day.
no h/o travel or consumption of outside food.
no h/o constipation
no h/o burning micturition.
no h/o rash.
no h/o chestpain, palpitations.
ASSOCIATED DISEASES:
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PAST HISTORY:
h/o HTN since 5 months and is on regular medication.
h/o DM since 5 months. Was diagnosed on development on left pedal edema.
h/o thyroid disorder since 3 years and is on regular medication.
No K/C/O Epilepsy, TB, CAD, CKD.
No h/o surgical processes.
No h/o Blood transfusions.
PERSONAL HISTORY:
Married since 40 years.
Manual labour by occupation.
Is on a mixed diet.
Reduced appetite since 3 days.
Inadequate sleep since 3 days.
Has increased Bowel movements.
Has no known allergies.
Has no addictions.
FAMILY HISTORY:
h/o maternal uncle having HTN and DM.
Has N/K/C/O Strokes. No CAD, TB, Asthma or Epilepsy.
DRUG HISTORY:
GENERAL EXAMINATION:
-No palor
-No Icterus
-No cyanosis
-No lymphadenopathy
-No pedal edema
-No clubbing of fingers
VITALS:
Temperature: Febrile - 100°F
Pulse: 150 beats per minute
Respiratory rate: —27 cycles per minute
Blood pressure: 90/60 mm of Hg
SPO²: 97%
GRBS: 125mg/dL
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 : Obese
No tenderness
No palpable mass
non palpable spleen
hernial orifices normal
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:
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ULTRASOUND REPORT:
GRAPHIC SHEET :
PROVISIONAL DIAGNOSIS:
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