24 year old with Amoebic dysentery with Iron Deficiency Anaemia

 A 24year old women  presented to our casuality at 10 :30 am on 21-11-20 with complaints of 

Pain abdomen since 10 days 

Vaginal discharge (curdy white)since 20 days  

Low grade fever since 10 days 

Vomting since 2 days 

Loose stools with blood since 10 days 

( first 4-5days : 6-7 episode/ day 

Past 5 days : 3-4 episodes : water in consistency ; mixed with frank blood ;no pain per rectum /no mass per rectum 

H/o unable to pass  flatus + 

Loose stools occur following food intake and pain abdomen 

No h/o passage of worms 

No h/o outside food intake 

H/o non veg intake + ( 2 days prior to onset of diarrhoea ) 


 HISTORY OF PRESENT ILLNESS

- c/o pain abdomen , colicky type in umbilicus , hypogastrium , left hypochondrium , left lumbar area . Intermittent type of pain , 

Nausea+ 

Loss of appetite + 

Fatigue + 

H/o fever - low grade @ night times 

Vaginal discharge is curdy white, foul smelling,associated with itching.

c/o vomiting since 2 days - 2 episodes/ day contains food  , no black vomitus , non projectile 

C/o decreased urine output and burning micturition

Assoc with generalised weakness , palpitations and giddiness + 

No h/o cough and chest pain 

PAST HISTORY

No h/o similar complaints in the past

Not a k/c/o DM/HTN/TB/Asthma/Epilepsy/Thyroid/cardiovascular abnormalities

Tx/ h/0 : Pt was advised oflox 2 outside 

                2 LSCS 

Menstrual History

Age of menarche:13yrs

5/30 cycle

No clots and dysmenorrhoea

Vitals

Temp - 98.2 

Pulse - 110/ min 

Bp-90/60mmhg

Rr-18cpm

Per Abdomen - tenderness at umbilicus , hypogastrium 

Cvs - s1 and s2 + ,no murmurs

Palor present



Cbp

cue

Lft

Rft

Serum electrolytes
reticulocyte count
stool for occult blood
Hemogram
usg abdomen


Diagnosis

Amoebic dysentery with vaginal candidiasis with iron deficiency anaemia.

TREATMENT 

Day 1  

1.Plenty of oral fluids 2-3L/day

2.ors sachets in 1 lit of water drink 200ml after each loose stool 

3.soft oral diet

4.Inj.ciprofloxacin 500mg/Iv/Bd

5.Inj.Metrogyl 100ml/Iv/tid

6.Inj.Pan 40mg/Iv/od

7.inj.zofer 4mg/iv/tid

8.Inj.optineuron1amp in 100ml Ns/iv/od

9.T.Dolo 500mg/po/bd

10.Inj.Buscopan /IM/sos

11.Ivf Rl 2 units Dns 2 units @75ml/hr

12.T.sporolac Ds Tid 

13.Candid V6 vaginal pessary

Day 2

C/o 2 episodes of loose stools since last night 1 episode and blood tinged loose stool yesterday morning,pain abdomen.nausea present

1.Plenty of oral fluids 2-3L/day

2.ors sachets in 1 lit of water drink 200ml after each loose stool 

3.soft oral diet

4.Inj.ciprofloxacin 500mg/Iv/Bd

5.Inj.Metrogyl 100ml/Iv/tid

6.Inj.Pan 40mg/Iv/od

7.inj.zofer 4mg/iv/tid

8.Inj.optineuron1amp in 100ml Ns/iv/od

9.T.Dolo 500mg/po/bd

10.Inj.Buscopan /IM/sos

11.Ivf Rl 2 units Dns 2 units @75ml/hr

12.T.sporolac Ds Tid

13.Candid V6 vaginal pessary

Day 3

C/O 2 episodes of normal consistency stools since yesterday morning

No fever spikes

1.Plenty of oral fluids 2-3L/day

2.ors sachets in 1 lit of water drink 200ml after each loose stool 

3.soft oral diet

4.Inj.ciprofloxacin 500mg/Iv/Bd

5.Inj.Metrogyl 100ml/Iv/tid

6.Inj.Pan 40mg/Iv/od

7.inj.zofer 4mg/iv/tid

8.Inj.optineuron1amp in 100ml Ns/iv/od

9.T.Dolo 500mg/po/bd

10.Inj.Buscopan /IM/sos

11.Ivf Rl 2 units Dns 2 units @75ml/hr

12.T.sporolac Ds Tid

13.Candid V6 vaginal pessary

Comments

Post a Comment

Popular posts from this blog

68 year female with hypertension urgency? steroid induced

Image
A 68 year old female presented to ophthalmology opd with complaints of diminished vision since 6 months,diagnosed with right eye SMC admitted for cataract surgery referred to medicine opd in view of high bp recordings Bp 220/120 mm of hg No ℅ Headache vomitings dizziness  neck pain is present occasionally  No pedal edema  shortness of breath on exertion present  palpitations absent She is using dexamethasone  and acyclofenac for body pains as prescribed by RMP  not a known case of hypertension, diabetes mellitus, asthma ,epilepsy, CVA ,CAD Personal history: Diet :vegetarian diet appetite: normal Bladder and bowel :regular . Sleep:adequate.  addictions: none General Examination: Patient is conscious coherent and cooperative  No pallor ,icterus,cyanosis, clubbing, lymhadenopathy,edema Vitals: Temperature: Afebrile Pulse: 78bpm Respiratory rate: 19cpm Bp: 190/100 mm of hg Spo2: 98% at RA Systemic examination:  Cvs: S1 S2 heard no additional sounds or murmurs Rs: NVBS Abdomen: soft,non ten
Read more

BIMONTHLY INTERNAL ASSESSMENT

Image
  26 year old woman with complaints of altered sensorium somce 1 day,headache since 8 days,fever and vomitings since 4 days More here:  https://harikachindam7.blogspot.com/2020/12/26-year-old-female-with-complaints-of.html Case presentation  links:  https://youtu.be/fz9Jssoc-mA https://youtu.be/d4lLX04oL8 https://youtu.be/CSCxw2zp7Oc a). What is the problem representation of this patient and what is the anatomical localization for her current problem based on the clinical findings? problem: • headache 1 -2 times /week since 1 month and along with neck pain  • both hands small joint pain and later elbow and shoulder involved. she diagnosis as SLE •  she present to causality with altered sensorium and irrelavent talk  • history of vomittings and generalised weakness ,decreased appetite ,unable to walk  • history of low grade fever and joint pain  Anatomical location  : she has low grade fever,chronic headache along with neck pain and altered sensorium.....suggested may be problem in the 
Read more

27 M VIRAL PYREXIA WITH THROMBOCYTOPENIA

Image
 A 27 yr male patient came with complaint of fever since 3 days which is of high grade and continuous type, aggrevated during night and relieved on taking medication and associated with chills since 2 days.  Patient says he had back ache and joint pains in lower limb associated with fever.  C/o generalised weakness since 4 days.  No H/O headache No h/o vomitings No c/o cold, cough No H/O burning micturition  No h/o hematuria No H/O diarrhoea, constipation No H/O abdominal pain & tenderness No H/O bleeding manifestations and rash No H/O palpitations,chest pain, syncopal attacks No H/O loss of apetite, decreased sleep No H/O loss of consciousness/fatigue/weakness PAST HISTORY: Not a K/C/O Diabetes, Hypertension, Asthma, Epilepsy,T.B,CVA,CAD No past history of similar complaints No past history of hospitilization or surgery FAMILY HISTORY: No H/O Diabetes, Hypertension, Asthma, Epilepsy, Tuberculosis, CVA, CAD.  PERSONAL HISTORY: Diet :mixed Sleep :adequate  Bowel and bladder :regular
Read more