Case of a 19 year old male with diarrhoea and abdominal pain

 CHIEF COMPLAINTS

This is a case of a 19 year old male wh presented to the casualty with chief complaints of 

• loose stools  from the past 3 days 
• two episodes of vomiting one day before admission . 
• Abdominal pain on the left side 3 days 

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 3 days back . 

3 days ago the patient attended a function where he consumed oily food. From the next day , the patient had loose stools - 5 to 6 times a day . 

On the day of admission , he visited a local hospital where he was diagnosed with acute appendicitis and was told that he would need  surgery. After which he presented to the casualty with the following complains -

Abdominal pain in the left illiac fossa - continuous , increases during defecation and on turning to the left .

He also had 2 episodes of vomiting (on in the morning other at night) -bilious vomiting, non projectile. 

The patient had 2 episodes of fever 

• 102 degree F (last evening )
• 99 degree F (morning)

 

PAST HISTORY 

The patient is not a known case of DM , TB, Asthma .

FAMILY HISTORY 

No relevant family history

PERSONAL HISTORY 

• Diet- mixed diet 
• Sleep - normal 
• Apetite- Normal 
• Bladder movements - Normal 
• Bowel movements - Diarrhoea
• Addictions -
• The patient has a history of occasionally consuming toddy from  very young age. 
• consumption during festivals 
• last consumption on 4th february - one glass 

GENERAL EXAMINATION
 

The pateint is concious , coherent oriented to time place and person 

Pulse rate - 80 beats per minute 

Temperature - afebrile 

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

SYSTEMIC EXAMINATION 

CVS

• S1,S2 heard 
• no thrills or murmurs 

RESPIRATORY SYSTEM 

• normal vesicular breath sounds 

PER ABDOMEN 

INSPECTION 

• Umbilicus is central and inverted
• No engorged veins, scars .
• No visible pulsations  

PALPATION 

• Tenderness in the left lumbar region
• No hepatospleenomegaly

PERCUSSION- 

• No free fluid 

AUSCULTATION

• bowel sounds heard 

 

CNS -

The patient is concious ,coherent oriented to time place person . 

No focal neurological deficits

INVESTIGATIONS 

PROVISIONAL DIAGNOSIS

?Gastroenteritis

TREATMENT DAY 1- 

INJ PANTOP 40mg IV

INJ ZOFER 4 mg IV

IV FLuids -NS and RL 70 ml/hr

DAY 2

S: Tenderness decreased in left iliac fossa compared to yesterday 

O: 

• PR; 82 bpm
• BP110/70mmhg
• Per Abdomen : Tenderness decreased in the left iliac fossa 

A; Gastroenteritis 

P: 

• INJ PANTOP 40mgIV
  
• INJ ZOFER 4mg IV
• IV Fluids NS and RL 70ml/hr