Gm case-3


Case scenario....

Hi, this is P.Minnu ,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 minute

Respiratory 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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