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?