2nd degree Paralytic lieus

SCENARIO:

A 50 year old female presented to the OPD with SOB and constipation.


COMPLAINTS AND DURATION

  • Constipation since 3 days

  • Pain in abdomen

  • Shortness of breath

  • Nausea and vomiting since 3 days
  • Pain in chest since 2 years 

HISTORY OF PRESENT ILLNESS

Patient apparently asymptomatic 2 months ago, developed shortness of breath, pain in abdomen(right side tenderness and right hypochondriac pain) and constipation.This was followed by 4 episodes of vomiting


HISTORY OF PAST ILLNESS

  • Not a K/C/O HTN, DM, asthma, epilepsy

  • Renal caliculi treated conservatively 2 years ago








TREATMENT HISTORY

No significant treatment history


PERSONAL HISTORY

  • Appetite - Normal

  • Bowels- Constipated

  • Micturition -Normal

  • No known allergies

  • No addictions


FAMILY HISTORY

  • No significant family history


MENSTRUAL HISTORY

  • Hysterectomy done 15 years ago for fibroid bodies


PHYSICAL EXAMINATION

  1. GENERAL

  • Pallor - Yes

  • Icterus - No 

  • Cyanosis - No

  • Clubbing of finger/toes - No

  • Lymphadenopathy - No

  • Oedema - No

  • Temperature - afebrile 

  • Pulse rate 70 b/min

  • Respiration rate - 17/min

  • BP 1400/80 mmHg 






SYSTEMIC EXAMINATION 

  1. CARDIOVASCULAR SYSTEM

  • Thrills - No 

  • Cardiac sounds - S1 , S2 positive


  1. RESPIRATORY SYSTEM 

  • Dysponea - No 

  • Wheeze - No

  • Position of trachea - Central 

  • Breath sounds - Vesicular  


  1. ABDOMEN

  • Shape of abdomen - Scaphoid
  • Tenderness present 
  • Palpable mass absent 
  • Liver and spleen non palpable 
  • Bowel sounds - Sluggish

  1. CENTRAL NERVOUS SYSTEM 

  • Level of consciousness 

  1. Alert

  2. Stuporous 

  • Signs of meningeal irritation

  1. Neck stiffness - no

  2. Kerning’s sign - no

  • Cranial nerves - normal 

  • Motor system - normal

  • Sensory system - normal 

  • Glasgow system - normal 

  • Cerebral signs

  1. Finger nose coordination - Yes

  2. Knee Heel In-coordination - Yes


F.MUSCULO SKELETAL SYSTEM - normal 


G. SKIN - normal

 

H. EXAMINATION OF BREAST - normal


I. EXAMINATION OF ENT - normal


J.EXAMINATION OF TEETH AND ORAL CAVITY - normal


K. EXAMINATION OF HEAD AND NECK  - normal



INVESTIGATIONS












TREATMENT

  • IV fluids
  • Soap water enema 
  • Buscopan SOS 
  • Pan D
  • Duphalac  







PROVISIONAL DIAGNOSIS/ DIAGNOSIS 

  • Constipation with 2nd degree paralytic ulcer





Comments

Post a Comment

Popular posts from this blog

Reduced EF secondary to congestive cardiac failure

Image
   This is an online E-log book to discuss our patient's identified health data shared after taking his/ her guardians signed informed consent. CASE SCENARIO: This is a case of an 85 year old male presented to OP with Shortness of breath, Vomiting since 2 days and dysphasia. COMPLAINTS AND DURATION Shortness of breath  Vomiting since 2 days dysphagia  HISTORY OF PRESENT ILLNESS Diagnosed with Heart disease 2 years ago. Shortness of breath as of one week ago followed by Dysphagia and vomiting as of 2 days. HISTORY OF PAST ILLNESS Not a K/C/O HTN, DM, asthma, epilepsy Unhealed ulcerated foot for the past 10 years. Surgery done to graft thigh muscle to the foot but has shown no improvement TREATMENT HISTORY Thigh muscle graft to feet for non healing ulcer Has been regularly tested for DM and HTN. PERSONAL HISTORY Appetite - lost Bowels- regular Micturition -normal No known allergies Quit alcohol and Cigarettes 8 years ago on recommendation by physician for non healing u...
Read more

Osteoarthritis secondary to oliguria and constipation

Image
This is an online E-log book to discuss our patient's identified health data shared after taking his/ her guardians signed informed consent.   Here we discuss our individual patient problems through a series of inputs from available Global online community of experts with an aim to solve the patients  clinical problem with current best evidence based input.   This E-log also reflects my patient centered online learning portfolio. I have 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. CASE SCENARIO: A 65 year old male presented to the orthopaedic OPD with complaints of inability to climb stairs, pain in knees and ankles oliguria and pain during defecation. COMPLAINTS AND DURATION Chronic back pain since 1 year Pain in the knee joints and along the ch...
Read more

Severe anemia associated with intestinal bleeding

Image
  This is an online E-log book to discuss our patient's identified health data shared after taking his/ her guardians signed informed consent.   Here we discuss our individual patient problems through a series of inputs from available Global online community of experts with an aim to solve the patients  clinical problem with current best evidence based input.   This E-log also reflects my patient centered online learning portfolio. I have 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. CASE SCENARIO: A 32 year old female presented to the OPD with dysphagia, significant weight loss, pedal oedema, SOB on exertion, blood in stool and pain during defecation. COMPLAINTS AND DURATION Dysphagia to solids since 4 months (grade-3) Weight loss of 15 kgs ...
Read more