IMS Case 2

1. IMS Case 2

2. Personal Details Name : NBM Registration No. : 14253 Age : 54 Occupation : Nurse Race : Malay Religion : Muslim Marital Status : married with 3 children

3. Diarrhea for 9 times and vomiting for 2 times since 7pm last night (as of date of history-taking) Chief Complaint

4. History of Presenting Illnes NBM complaint of diarrhoea for nine times and two bouts of vomiting since last night at around 7pm. She tried to relieve it by applying ointment. However, the pain got worse and woke her up from her sleep. Her husband brought her to A&E and she was admitted at 3.45am. The stool was watery and yellowish but no blood seen. The vomitus was undigested food and no blood. There was localized abdominal pain at the epigastric area which she described it as a cramping pain of grade 7. The pain usually came before she had the urge of passing stool and usually relieved slightly after passing the watery stool. Aassociated symptoms: dizziness, headache, and nausea. She said that she had her lunch yesterday 1pm at a mamak with her colleague. She ate rice with sambal fish and curry. However, her colleague didn’t experience the same problem as her.

5. Systemic Review There were no chest pain or shortness of breathe. Her urination was normal. Her appetite was reduced, but no significant weight loss. Energy level was low.

6. Past Medical History She had an appendectomy done in 1992. She is also having hypercholesterolemia and is currently taking simvastatin for it. She was diagnosed as diabetic since 2003 and taking Glucovance for it. She goes for a regular check up every three months.

7. Obstetric History She gave birth of her 3 children through cesarean section. She gave birth of her 1st son in 1983, complicated by difficulty of labour due to small pelvic, and her child weight 3.38kg.. Her 2nd son was born on 1987 and he weight 3.37kg, with G6PD deficiency and jaundice. She gave birth of her 3rd daughter in 1991, 3.05kg, with jaundice. Besides that, she had gestational diabetes when she’s pregnant with her 3rd child, which resolved itself after giving birth.

8. Family History Her father passed away when 73 years old (last year), due to complication of diabetes. Her mother is 77 years old now. She’s healthy except that she has leg pain on and off. She has 2 sisters aged 40 and 38. Both of them are healthy. She has 2 sons and 1 daughter, aged 26, 22, and 18. All of them are healthy.

9. Social History She works as a nurse in hospital Port Dickson. She’s staying together with her husband and children. She doesn’t smoke or drink any alcohol beverage. Most of the time she has her meals outside. She only cooks during weekend. She doesn’t exercise.

10. Physical examination • NBM, is lying comfortably on a supine bed, conscious, alert, cooperative and communicative. • No signs of respiratory distress and not in obvious pain. • She’s well hydrated. • There’s an IV normal saline attached to her left hand. • Vital Signs: • Radial Pulse: pulse rate is 100 bpm, regular in rhythm, strong in volume and no radio-radial delay. • Blood pressure: 108/80mmHg. • She has low grade fever, 37.5 oC. No raised JVP.

11. Physical Examination • Hands: • warm and moist. • Capillary Refill was less than 2 sec • no clubbing, no peripheral cyanosis, no palmar erythema, no leukonychia, no koilonychias,and no thenar or hypothenar muscle wasting and no fine or flapping tremor. • Eyes: • no jaundice or pallor, no corneal archus, no Xanthelesma. • Mouth: • good oral hygiene. • Hydration was good • no fetor hepaticus, no central cyanosis, no jaundice, no angular stomatitis, no leucoplakia and no glossitis.

12. Physical Examination • Chest: • size and shape of the chest is normal. There were no spider naevi, and no loss of axillary hair. • The apex beat was not palpable. There were no palpable trills and no parasternal heave. • On auscultation, first and second heart sounds heard. There were no added heart sounds and no murmurs heard. • There was no tracheal deviation. • Tactile vocal fremitus was equal on both sides. • On percussion, the chest wall was resonant on both sides. • On auscultation, vesicular breath sounds were heard. There was equal vocal resonance on both sides. Basal crepitations of the left and right lung were present.

13. Abdomen: • normal size and shape. There is a lower section cesarean scar from umbilicus to suprapubic area, around 8cm. There is an appendectomy scar, around 4cm. No dilated veins or obvious peristalsis seen. • There is tenderness at epigastric region and right iliac fossa region upon deep palpation. No deep masses palpated. • On auscultation, normal bowel sounds are heard. • Lower Limbs: • There was no pitting oedema, no tenderness of limbs, both limbs were warm and moist, no ulcers and no loss of hair. • Peripheral pulse were palpable, symmetrical, and strong volume.

14. Differential diagnosis: • Food poisoning, • drugs-induced diarrhea, • acute pancreatitis.

15. Investigations: • Liver Function Test • Renal Profile • ECG • Results: There is no abnormal finding

16. Acute gastroenteritis Provisional Diagnosis: