GM case presentation

GENERAL MEDICINE CASE PRESENTATION 





CASE SCENARIO 

28,JUNE,2022

Pt aged 28 years female house wife came to opd with chief complaints of loose stools since 20 days associated with abdominal pain and generalised weakness

HISTORY OF PRESENT ILLNESS 

She was asymptomatic 30 days back then when  stools started which is less in quantity assosiated with abdominal pain that releaved after passing stools not associated with any blood in stools associated with generalised weakness 

HISTORY OF PAST ILLNESS 

She visted 3 hospitals for same reason in past 15 days  
No H/o DM, HTN, Asthma , epilepsy, TB . 
she had 3 c section before .


TREATMENT HISTORY 

NO history of previous medication 


PERSONAL HISTORY 

Married 
Mixed diet 
Loss of appetite 
Irregular bowel habit 

Regular mensus 

FAMILY HISTORY 

NO H/O :-HTN,DM ,EPILEPSY ,TB 


GENERAL EXAMINATION 


NO pallor 
    No   .icterus 
       No .cynosis 
     No  .lymphadenopathy 
       No.clubbing 

PHYSICAL EXAMINATION-:

.temperature-:afibrile 
.pulse rate  -:82/min
.resp rate -:18/min 
.Bp             -:90/70


 SYSTEMIC EXAMINATION 

CVS-; 
        S1,S2 HEARD 
        NO MURMERS 

RESPIRATORY SYSTEM-:
         No dyspnea 
          No wheeze 
          Position of trachea -;central 
ABDOMEN-:
          Shape scaphoid 
          Tenderness in right lumber region 
          No palpable mass 
           No palpable spleen and liver 

CNS-:
         Consious, coherent ,cooperative 
         Speech normal
         No neck stiffness
         
SENSORY SYSTEM 
        Able to percieve-:pain , temp.

   Provisional diagnosis :: Irritable bowel syndrome  

TREATMENT HISTORY 

1)TAB SPOROLAC DS×PO TID 

2)MEVA C PO /BD 

3)IVF IONS @100ML/HR

Investigations

Microbiological examination revealed no pus cells and no oval cysts .












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