Case of 18 years old female with c/o of VOMITING AND LOOSE STOOLS, INVOLUNTARY MOVEMENTS B/L UPPER AND LOWER LIMBS

 Case of 18 years old female with c/o of VOMITING AND LOOSE STOOLS, INVOLUNTARY MOVEMENTS B/L UPPER AND LOWER LIMBS

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CHIEF COMPLAINTS:

 

A 18 years old patient, who is a student (11th std) came to casualty with c/o 

1. Vomitings since 10 days

2. Loose stools since 10days

3. Abdominal pain since 4 days

4. Generaliseds weakness and giddiness since 1 day.

5. Involuntary movements of B/L upper and lower limbs at around 2:30 am.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 10days ago, then she developed 6-8 episodes of vomitings / day, non bilious, non projectile, non blood stained since 10 days.

Loose stools since 10 days- 3-4 episodes/day,watery,large volumes, non blood stained, subsided after 5 days.

Abdominal pain since 4 days-initially localised to lower abdomen later progressed to be diffused abdominal pain and non radiating.

Generalised weakness and giddiness since 1 day.

Patient was taken to local hospital 1 day back,where she had one episode of seizure (B/L Upper and Lower Limbs)?GTCS associated with drooling of salive,uprolling of eyeballs,involuntary micturition, episode lasted for 2 mins, following that patient was in a state of confusion and was not able to identify the family members

Pt was given INJ.MIDAZ 2cc and INJ.LEVIPIL 500mg IV/stat and referred to our hospital for further evaluation and management 

No h/o fever,headache,cough,cold.

PAST HISTORY:

No similar complaints in the past

 H/O typhoid fever 4 months back

Not a k/c/o HTN,dm,asthma,TB,epilepsy,thyroid disorders 

PERSONAL HISTORY:

1.Diet-mixed 

2.Appetite:normal 

3.Bladder movements -regular 

4.Bowel: loose stools 10 days back(4-5 ep/day) subsided 5 days back

5. Sleep -adequate

6.Addictions-nil

MENSTRUAL HISTORY:

Age of menarche-12 years

Regular cycles - 30 days/ 4days

Associated with pain,no clots

DAILY ROUTINE: (before illness)

Wakes up at 7am

Fresh up and have breakfast by 8am 

Goes to college and comeback at 5pm (lunch 1-2pm)

At 6pm she has some snacks (tea/milk) and watches TV

At around 8pm she has her dinner and sleeps by 10pm.

FAMILY HISTORY: Insignificant 

TREATMENT HISTORY:

Patient was prescribed medications for abdominal pain 3 days ago (18/06/23) by an RMP- TAB. ONDANSETRON, TAB.METROGYL 400mg, TAB. RAPEPRAZOLE

Patient was given INJ.MIDAZ 2cc and INJ.LEVIPIL 500mg IV/stat at a local hospital after seizure episode.

GENERAL EXAMINATION:

The patient was examined in a well-lit room after informed consent was taken.

She is conscious, coherent, cooperative, well oriented to time, place and person, well nourished and moderately built.

No pallor, Icterus, Clubbing, Cyanosis, Koilonychia, Lymphadenopathy, Edema.

VITALS:

1. Temp: Afebrile 
2. BP: 110/80 mm hg
3. PR: 92bpm
4. RR: 20cpm
5. Spo2: 99% on RA
6. GRBS : 98mg/dl

SYSTEMIC EXAMINATION:

Per abdomen:

INSPECTION:

Scaphoid shape

All quadrants moving equally with respiration

No abdominal distension 

Umblicus is central and inverted 

No engorged veins

No scars and sinuses

No visible peristalsis

PALPATION:

All inspectory findings are confirmed 

Diffuse tenderness all over abdomen

No palpable liver or spleen

PERCUSSION: Dull note heard

AUSCULTATION: 

Bowel sounds heard 

No bruits.

CVS:

S1 S2 heard, no murmurs.

RESPIRATORY SYSTEM:

BAE+

Normal vesicular breath sounds heard

CNS: 

No focal neurological deficit 

INVESTIGATIONS:

22/6/2023

CBP:

Hb:  10.5 gm/dl

TLC:   6600 cells/ cumm

RBC:   4.54 million/cumm

PLT:   2.44 lakh/cumm

PCV: 33.2 vol%

Neutrophils:88%

Lymphocytes:10%

MCV:72.8fl

MCH:23pg

RFT:

Blood urea:  19 mg/dl

Serum creatinine: 0.8 mg/dl

Serum electrolytes: 

Na+:   140 mEq/l

K+:  4.3 mEq/l

Chloride :  102 mEq/l

LFT:

Total bilurubin:0.94mg/dl

Direct bilurubin :0.20 mg/dl

AST:16 IU/L

ALT:20 IU/L

Alk phosphatase:174IU/L

Total Protien:6.8gm/dl

Albumin:3.9gm/dl

CUE:

Albumin:nil

Sugars:nil

Pus cells:2-3/HPF

Epithelial cells:2-3/HPF

USG ABDOMEN AND PELVIS: Impression

Minimal Ascites

Internal echoes noted in urinary bladder ? Cystitis (co relate with CUE)

MRI BRAIN:

No abnormalities detected in brain

B/L hippocampus is normal.

Chest X-ray:

PROVISIONAL DIAGNOSIS: 

Seizures under evaluation 

?Acute gastroenteritis 

TREATMENT:

1. INJ. ZOFER 4mg IV/TID
2. INJ PAN 40mg IV /OD
3. INJ BUSCOPAN IV/BD
4. IV FLUIDS -NS,RL,DNS @100ml/hr
5. INJ. OPTINEURON 10mg
6. INJ METROGYL 500mg IV/TID
7. INJ. LEVETIRACETAM 500mg IV/BD

23/06/23

ICU BED 1

S:

C/o pain in hypogastric region 

No fever spikes

Stools passed  in morning 

O:

Patient is c/c/c 

Temp: 98.6 F

PR- 89 bpm

RR-18 cpm 

BP-100/70 mm of Hg

Spo2 -98% 

CNS: 

GCS- E4 V5 M6

Pupils NSRL

Tone- Normal in all four limbs 

Power - 

      Rt     Lt

UL 5/5   5/5   

LL 5/5   5/5   

Reflexes

      Rt     Lt

B - 1+.    1+

T - 1+.    1+

S.   -.     -

K - 2+.    2+

A - 1+    1+

Plantar 

Right-Flexor   Left-Flexor 

RS-B/L air entry present, NVBS

CVS- S1S2 present, no murmurs heard

PA- soft, tenderness present in hypogastric region,bowel sounds +

A:

  Seizures under evaluation -?drug induced

  ?ofloxacin

Acute GE

P:

1.IV FLUIDS 2NS,1RL1DNS@100ML/HR

2.INJ. LORAZEPAM 1mg IV/SOS(if sleep disturbances are present)

3.Monitor vitals