CASE SCENARIO

Pt aged 28 years female house wife came to opd with chief complaints of loose stools since 20 days associated with abdominal pain and generalised 
Weakness since 10 days

HISTORY OF PRESENT ILLNESS 

It was asymptomatic 30 days back then when  stools started which is less in quantity assosiated with abdominal pain that relevied after patting stools not associated with any blood in stools associated with generalised weakness 

HISTORY OF PAST ILLNESS 

No H/o DM, HTN, Asthma , epilepsy, TB . 
she had 3 c section before .

TREATMENT HISTORY 

NO history of previous medication 

PERSONAL HISTORY 

Married 
Mixed diet 
Loss of appetite 
Irregular bowel habit 
Regular mensus 

FAMILY HISTORY 

NO H/O :-HTN,DM ,EPILEPSY ,TB 


GENERAL EXAMINATION 


NO pallor 
       .icterus 
       .cynosis 
       .lymphadenopathy 
       .clubbing 

PHYSICAL EXAMINATION-:


.temperature-:afibrile 
.pulse rate  -:82/min
.resp rate -:18/min 
.Bp             -:90/70


 SYSTEMIC EXAMINATION 

CVS-; 
        S1,S2 HEARD 
        NO MURMERS 

RESPIRATORY SYSTEM-:
         No dyspnea 
          No wheeze 
          Position of trachea -;central 
ABDOMEN-:
          Shape scaphoid 
          Tenderness in right lumber region 
          No palpable mass 
           No palpable spleen and liver 

CNS-:
         Consious, coherent ,cooperative 
         Speech norml
         No neck stiffness
         
SENSORY SYSTEM :-
        Able to percieve-:pain , temp


INVESTIGATIONS 




ULTRASOUND 

Impression 

-slighty thickened caecum,IC junction and terminal ileum,descended colon
-few enlarged mesenteric lymph nodes



PROVISIONAL DIAGNOSIS 

●  irritable bowel syndrome 



TREATMENT HISTORY 

1)TAB SPOROLAC DS×PO TID 

2)MEVA C PO /BD 

3)IVF IONS @100ML/HR






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