45 Y/O FEMALE WITH PAIN IN ABDOMEN VOMITING HEADACHE

45 Y/O FEMALE WITH  PAIN IN ABDOMEN VOMITING HEADACHE


This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.
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CHIEF COMPLAINTS

Pain in abdomen since 4 days

Vomiting since 4 days

Headache since 1 day


HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 5 days back. 

Then around 7:30 pm on wednesday patient alleged to be bitten by a snake ( ? Viper) on right foot and taken to the local hospital.

ASV was taken and she was fine for 1 day. A/b complaint of swelling of right lower limb and went to local hospital for which ointment was advised. Swelling subsided.

Patient has had abdominal pain for the last 4 days. Squeezing type pain in periumbilical region agg. by vomiting. No radiation. Abdominal distension after food consumption.

Vomiting 2-3 episodes. Bilous food, not blood tinged. 


HISTORY OF PAST ILLNESS

No ℅ chest pain, palpitations, shortness of breath.

No ℅ SOB, PND

No ℅ burning micturition

No ℅ pedal edema, facial 



PERSONAL HISTORY

Normal appetite
Mixed diet[Non vegetarian]
Constipation [once every 2-3 days]
Micturition normal
There are no allergies 


FAMILY HISTORY

No significance

General examination
Pallor is present

NO Icterus

NO Cyanosis

NO Koilonychia

NO Lymphadenopathy

NO Edema 

NO Malnutrition

VITALS

BP : 150/90 mm/Hg

Pulse rate : 96 /min

Respiratory rate : 24 cycles / min

SPO2 at room air :99 %

GRBS 180 mg%


SYSTEMIC EXAMINATION 

CVS
No Thrills
S1 and S2 heard +
No Cardiac murmurs
 
RESPIRATORY SYSTEM

No Dyspnoea
NO Wheeze
Central trachea
Vesicular Breath sounds

ABDOMEN
Shape : Scaphoid
Tenderness in Periumbilical Region

No palpable mass, fluid , bruits

Bowel sounds are heard

CNS 
Is Conscious

Normal speech

No Signs of meningeal irritation

PROVISIONAL DIAGNOSIS
AKI decreased evaluation 
T Thrombocytogenic 


EXPECTED OUTCOME: Guarded



TREATMENT
AKI  2  to Acute tubular necrosis 2 to snake bite
T thrombocytogenic

VITALS 
Temperature : Afebrile

BP :140/90 mm Hg

PR = 78 beats/min REGULAR

CVS = S1 S2 + 

GRBS : 112 mg/dl





1] PLENTY OF ORAL FLUIDS 3 L/DAY

2] IVF - NS at 100 ml/hr 

         -RL at 100 ml/hr

3]INJ LASV 40mg/IV

4] INJ PAN 40mg/IV

5] INJ ZOFER 4 mg/IV

6]TAB BUSCOPAN PO/OD

7] TAB PCM 650 mg/PO

8] INJ THIAMINE 100 mg IN 100 ml /IV

9] BP/PR/TEMPERATURE CHARTING AND HOURLY

10]STRICT I/O CHARTING

11] GRBS CHARTING 8 HOURLY

12]INJ CEFMAXONE 1g/IV




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