18 years old patient came to Opd with chief complaint of headache since 1 week H/o of vomiting 2days back
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Chief complaints:
19 f with chief complaints of
Headache since 1 week
C/o vomiting 2 days back
C/o heaviness of chest since 2 days
C/o giddiness since 2 days 2 episode
19F intermediate student preparing for Btech entrance who lives in hostel presented with easy fatiguability, malaise and SOB on exertion since 10 days Vomiting and loose stools 7 days back and H/o grey coloured stool since 1 week.she noticed few drops of fresh blood during defecation.
Hopi:
•Patient was apparently Asymptomatic I month back, then she had 2 episodes of vomiting , non projectile, non bilious, food particles content.symptomatically a/w headache,
History of bleeding per rectum 1 episode - today
Headache - unilateral,throbbing type,non - radiating, ( - )photophobia,( - )phonophobia
Heaviness of chest: not associated with food intake, not associated with exertion
Past history:-
No similar complaints in the past
Not a know case of DM,ASTHMA,HTN,EPILEPSY,TB
Personal history
Diet: vegetarian
Appetite: decreased
Bowel and bladder movements: decreased
Appetite : decreased
Sleep : adequate
No aditions
Nutritional history:
Morning -
tiffen -idly,dosa,bonda,poori+chutney
Afternoon - sambar,curry,curd + rice
No snack
Night- curry, pickle,curd rice
Fruits - occasionally,
Vegetarian
Menstrual history: 3days/30 days,no clots,pain
H/o of irregular menstrual cycle
Menarche:17y
On examination:-
Pt is C/C/C well oriented to Time ,place and person
Pallor present
, NO=icterus,cyanosis,clubbing,or generalised lymphadenopathy
afebrile
Bp 110/70
PR -104bpm
Rr- 22cpm
Temp-98.6f
Input/output-600/450 ml
Grbs-107mg/dl
CVS-S1S2 heard
R/S - BAE +
CNS-NFND
P/A
Inspection:
Shape of abdomen normal
Umbilicus -central and inverted
No visible scars,sinuses,dilated veins
Hernial orifices normal
Palpation -no local rise of temperature
Tenderness in right iliac region
No guarding,rigidity,rebound tenderness
No hepatomegaly,spleenomegaly
Percussion-Resonant
Liver span- normal
Auscultation-
Bowel sounds +
INVESTIGATION
DAY 1
Serology: negative
Hemogram:
Peripheral smear:
Ultrasound:-
Day 2
CUE:-
Serum calcium:
Serum phosphorous:
Stool examination:-
Chest xray:-
2D echo:-
1.inj. zofer4mg/iv/sos
2.inj.iron sucrose200 mg in 100 ml ns over. 2 to 3 hrs
3.iron rich diet
4.tab dolo 650 mg p/o
5.syp.cremaffin 30ml/po
6.High fiber diet
7.anobliss ointment L/A
8.Sitz bath (betadine)
9.plenty of oral fluids
Discussion
DURING ICU DUTY
CPR for 48 year old male
Assisted in Intubation
Monitored vitals of the patient.
Took ABG samples
Inserted Foleys catherter
DURING NEPHROLOGY
Assisted in central line under the guidance of DR. Bharath
Monitored vitals of patients during dialysis
DURING WARD DUTY
Collected venous samples for routine investigations
Updated soap notes
