Case of pain abdomen

 I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

2017 batch 

Name :- Kattekola Sathwik

Roll no :- 58

Case details

A 13 yr old boy studying 6th standard has come to the OPD with the following history

History of presenting illness

The patient was apparently asymptomatic 2 days ago. Then he developed high grade fever which was releived on medication but never reached base line. At the time of onset of fever, he did not have any complaints of Nausea,vomiting,cough,pain abdomen.

As the fever was not releiving he was taken to the local hospital where supportive care was given .

Today he developed diffuse pain abdomen which was not radiating to back.No aggrevating and releiving factors 

Fever chart :- 

PAST HISTORY :

Not known case of DM2 , Hypertension , Asthma , TB , Epilepsy .

PERSONAL HISTORY :

Diet- mixed

Appetite- normal

Sleep- adequate

Bowel and bladder movements- regular

Occasional alcohol intake +

No known allergies

FAMILY HISTORY: Not significant

General physical examination

Patient is conscious coherent cooperatove

 

Moderately built and nourished

Pallor :-absent 

 

Icterus :-Absent

Cyanosis :- absent

 

Clubbing :-Absent

Lymphadenopathy :-Absent

Pedal edema :-Absent

Vitals at time of admission

• Temp - 99 F
• PR- 72 bpm
• RR- 22 cpm
• BP- 110/70 mmHg
• SpO2- 98% RA
• GRBS- 126 mg/dl

Per abdomen 

Inspection

• Abdomen is scaphoid in shape 
• All quadrants are moving equally with respiration
• Umbilicus is central and inverted
• No scars sinuses fistulae

Palpation

• All the inspectory findings are confirmed
• There is no local rise of temperature
• Tenderness in epigastric, left hupochondriac ,left lumbar , left iliac, And right iliac region 
• Soft 

Percussion:- Tympanic note 

Auscultation :- Bowel sounds heard 

Other system examination 

Respiratory system 

• Chest is bilaterally symmetrical
• Trachea is central
• On inspection and palpation, the movements are found to be equal on both sides
• Percussion :- Liver dullness at 5th intercoastal space
• Auscultation :- Normal vesicular breath sounds heard 

Cardiovascular system

• Precordium is normal
• Apex beat felt at 5th intercoastal space 1 cm.medial to mid clavicular line 
• S1 S2 heard 
• No murmurs

CNS :- No focal neurological deficit

Provisional diagnosis :- ? VIRAL PYREXIA WITH PAIN ABDOMEN FOR FURTHER EVALUATION 

Investigations

Hemogram 

• HB :-12.2
• Total WBC :- 10000
• PCV :-36.5
• MCH :-26
• MCV :- 79.8
• Platelets :-2.46 Lakh 

CUE 

• No sugars and albumin 
• Pus cells :-2-3
• Epithelial cells :- 2-3 

LFT

• Total bilirubin:- 0.56
• Direct bilirubin :- 0.17
• AST :-18
• ALT :-10
• TP :-5.9
• Albumin :-4.0

Serum creatinine:-0.4

Blood urea:-12

Electrolytes 

• Sodium:-139
• Potassium:-4.1
• Chloride :98

CXR 

USG Abdomen 

ECG

TREATMENT : 

1. Inj MONOCEF 1gm IV BD

2. Tab Dolo 650 mg PO BD 

3. IVF NS with OPTINEURON @ 75 ml/hr

4. Inj Neomol 1 gm IV SOS

5. Vitals monitoring every hourly

6. Strict I/O charting.