18y old with pain abdomen

  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.


Here is a case i have seen:


Case Discussion:

A 18y old male who is a student, presented with complaints of pain abdomen from past 4 months occuring intermittently. He also complaints of vomitings along with pain abdomen

Pain was dull aching localising to peri-umbilical region with no aggravating factors or relieving factors

After pain subsides patient complaints history of loose stools which was small in amount for next 2-3 days with 4-5 episodes per day. Stool was mucoid in consistency, not associated with bleeding or melena

Patient also has intermittent episodes of constipation intervening with episode of diarrhoea

Patient has history of fever from 2days -low grade intermittent

Past history

Not a k/c/o hypertension, Diabetes mellitus , asthma , TB, epilepsy.

Drug history:

no known drug allergies

PERSONAL HISTORY:

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel habbits: constipation since 2 days

Bladder: normal

family history:

not significant

general examination :

Pt is C/C/C , moderately built and moderately nourished

No pallor , icterus , clubbing ,cyanosis lymphadenopathy, pedal edema.

Vitals :

Afebrile

BP :110/60mm hg

Pulse : 70bpm

Resp rate : 22cpm

Spo2 : 99% @ RA

CVS 

Cardiac sounds : S1 S2 heard 

No murmurs heard 

Respiratory system 

Normal vesicular breath sounds heard

Bilateral air entry present

Per Abdomen

Shape : scaphoid, soft, no  local rise of temperature.

Tenderness present over peri-umbilical region

no palpable mass

hernial orifice : free

no free fluid , no bruits heard

liver and spleen - not palpable

bowel sounds- heard

CNS 

Patient is conscious, coherent, cooperative well oriented to time place and person. 

Higher mental functions- normal

cranial nerves- intact 

motor system- normal

sensory system - normal

 
















Provisional diagnosis: IRRITABLE BOWEL SYNDROME

treatment given: Inj. buscopan im sos
                                  Inj. pantop 40mg iv od
                                  Inj metrogyl 400mg iv tid
                                  IV fluids 
                                  Tab. sporolac ds po tid





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