Gm case 4

 March 5th 2023



Case scenario....


Hi, this is sai kaushik , 3 rd BDS student. This is an online eblog book to discuss our patient's health data after taking his consent. This also reflects my patient centered online learning portfolio.


CASE SHEET:


A 7 year old female with sever vomiting and loose stools.


Chief Complaint:


loose stools for 3days


vomiting for 3 days


Abdominal pain for 3 days


HISTORY OF PRESENT ILLNESS:


3 Days earlier patient was asymptomatic. 


Later she developed loose stools and vomiting 3 episodes in a day.


 The stools was watery.


 Frequency was 4 times a day. 


Colour was yellow. 


Stool has food content.


The vomiting contained food particles. 


Frequency was thrice a day. 


Abdominal pain in lumbar region on and off for 3 days. 


The pain was intermittent. 


Dull pain is observed.


PAST HISTORY:


No similar complaints in the past.


PERSONAL HISTORY:


Occupation: student(2nd grade)


Appetite: lost


Diet: non- vegetarian


Bowel: regular


GENERAL EXAMINTION:


Pallor : Yes


Icterus: no


Cyanosis: no


Clubbing: no


Lymphadenopathy: no


Edema: no


VITALS:


Temperature: 96F


Pulse: 72 beats per miRespiratory rate: 24 cycles per minute

Blood pressure:80/60 mm/Hg

SPO2:  98%

SYSTEMIC EXAMINATION:

Cardio Vascular System:

Cardiac sounds: S1, S2 heard

Cardiac Murmur: no

Abdomen: soft

Tenderness: no

No organomegaly

Nervous system: child was nervous

PROVISIONAL DIAGNOSIS:

Dehydration


Questions from patient

How much water do I have to consume each day?

How do you treat dehydration?

Questions from myside

Is the dehydration because of sodium potassium imbalance?

Is frequent urination one of the reason for dehydration?

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