A 14 year old female patient with vomitings and pain abdomen

August 4,2021

NAME : G. NANDINI , 3 rd sem

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INTRODUCTION :

14 YEAR OLD WITH VOMITINGS AND PAIN ABDOMEN

CASE HISTORY AND CLINICAL FINDINGS :

A 14 year old female student  resident of nalgonda came to Casuatly  on 1-08-2021 with chief complaints of 2-3 episodes of  vomitings since morning.

 

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 5 days back then she developed fever which was high on grade , intermittent relieved on medication, fever subsided 1 day back. Now the patient had 2-3 episodes of vomitings, which was non projectile, non bilious, which contains food particles.  

 No H/O  cough, cold , SOB

 No H/O   pain abdomen , loose stools, malena

 No H/O rash

PAST ILLNESS :

NO H/O  Diabetes, hypertension, Tuberculosis,asthama, epilepsy, thyroid, CAD, CVD

PERSONAL HISTORY :

Mixed diet

Normal appetite

Adequate sleep

Regular bladder and bowels movements

No addictions

FAMILY HISTORY :

No similar complaints in the family. No history of diabetes, hypertension,asthma, TB, CAD, CVD

GENERAL EXAMINATION : 

Patient was conscious, coherent, co - operative. 

 Well oriented to time, place, and person. 

Moderately built and moderately  nourished. 

No pallor

No clubbing

No cyanosis

No lympadenopathy

No edema

VITALS :

TEMPERATURE-AFEBRILE

PR-96BPM

RR-18CPM

BP-100/70 MM OF HG

SPO2-98 %AT RA

GRBS-150MG/DL

SYSTEMIC EXAMINATION :  

PER ABDOMINAL EXAMINATION :

INSPECTION -

Shape - scaphoid

Umbilicus - central and inverted

Movements with respiration - equal in all quadrants rises with inspiration  and falls during expiration .

No visible pulsations

No visible scars or sinuses seen

No engorged veins

PALPATION :

No local rise of temperature

No tenderness in any quadrants of abdomen, liver and spleen - impalpable ( no organomegaly) 

PERCUSSION :

Tympanic note

AUSCULTATION :

 Bowel sounds present 

CVS EXAMINATION :

S1, S2 heard

No murmurs

Apical impulse at 5 th intercostal space lateral to mid clavicular line

RESPIRATORY SYSTEM EXAMINATION :

Trachea - midline

Bilateral air entry present

Normal Vesicular breath sounds heard

No additional sounds

CNS EXAMINATION :

Gait - normal

Sensations - present

Cranial nerves - intact

Reflexes - preserved

INVESTIGATIONS :

CHEST X - RAY PA VIEW NAD

ECG- NO SIGNIFICANT CHANGES

 HAEMOGRAM :1/8/2021

HB12.77GM

TLC4300 CELLS/CU MM

PLATELETS-54 000CELLS/ CU MM

RBC -NORMOCYTIC NORMOCHROMIC

HAEMOGRAM-3/8/2021

HB-11.7GM

TLC-5000 CELLS/CU MM

PLATELETS-1.2 LAKHS/CU MM

RBC-4.25 MILLIONS/ CU MM

PCV.34.8 VOL%

BLOOD UREA : 14 mg/dl

SERUM CREATININE : 0.8 mg /dl

SERUM ELECTROLYTES ( Na , k, cl  ) 

SODIUM  : 135 mEq/L

  

POTTASIUM : 4.3mEq/L

CHLORIDE : 98mEq/L

COMPLETE URINE EXAMINATION :

COLOUR : pale yellow

 

APPEARANCE: clear

REACTION: acidic

SP  GRAVITY: 1.010

ALBUMIN : Trace

SUGAR : Nil

BILE SALTS :Nil

BILE PIGMENTS: Nil

PUS CELLS :2-4

EPITHELIAL CELLS: 2-3

RED BLOOD CELLS : 3-4

CRYSTALS :Nil

CASTS :Nil

AMORPHOUS : Absent 

DEPOSITS 

OTHERS :Nil

LIVER FUNCTION TEST  (LFT) :

TOTAL BILLIRUBIN :0.75 mg / dl

DIRECT BILLIRUBIN : 0.20 mg / dl

SGOT (AST) :32 IUL

SGPT (ALT) :15 IUL

ALKALINE PHOSPHATE :201 IUL

TOTAL PROTEINS: 5.4mg / dl

ALBUMIN :3.0 mg/ dl

A/G RATIO :  1.29 mg /dl

BLOOD UREA 

SERUM CREATININE

SERUM ELECTROLYTES 

COMPLETE URINE EXAMINATION 

LIVER FUNTION TEST:

HAEMOGRAM

DIAGNOSIS :

FEVER WITH THROMBOCYTOPENIA

TREATMENT :

IVF -NS AND RL@100 ml/ HR CONTINOUS INFUSION 

INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD 

TAB.PAN 40 MG /OD 

TAB.DOLO 500MG/BD