Final Practical Examination General medicine Long case
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Date of admission : 08-02-2022
A 19 year old male with Abdominal pain and loose stools .
Chief complaint:
A 19 year old male student came to casualty with chief complaints of abdominal pain , vomiting episodes (2 -3) since 3 days , loose stools since 3 days.
History of present illness :
Patient was apparently asymptomatic 5 days ago. He went to a party and there he had some mutton and a glass of beer . After 2 days he developed pain in abdomen with 2 -3 episodes of vomiting, and 2-3 episodes of loose stools . Pain was continuous and radiating to the left lower abdomen . Stomach pain , cramping , fever , nausea , headache were present . He went to local hospital for initial treatment. As the pain doesn't got subsided and rather aggrevating, he came to this hospital for further treatment .
History of past illness :
Patient is a known case of hypertension since 2 years and on regular medication .
No H/o asthma , DM , epilepsy, TB ,CAD .
No H/o allergies
Family History :
No family history of similar illness .
Personal History :
Diet : Mixed
Apetite: Normal
Sleep : Adequate
No H/o addictions .
General Examination :
Patient is conscious , coherent , co operative and well oriented to time and place .
No pallor , cyanosis , icterus, clubbing , generalized lymphaadenopathy is observed .
VITALS:
Temperature : 98. 6°F
Pulse rate : 86 bpm
Respiratory rate : 17 cpm
BP : 110/80 mm of Hg
Systemic examination :
CVS :
S1 , S2 are heard
No murmurs
Respiratory system :
Bilateral entry of air is normal
No dyspnoea
No wheeze
Vesicular breath sounds are heard .
Abdomen:
Mild tenderness is seen
No palpable mass
No bruit
CNS :
Speech : Normal
No stiffness of neck
No neurological deficits .
Investigations:
Complete blood picture :
Haemoglobin - 14.7 gm/ dl
TLC : 10, 000 cells/ cu mm
Platelet count: 2.4 L
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