A 21 yr old male with vomiting, loose stools and pain abdomen
“A 21 yr old male with complaints of vomiting, loose stools and pain abdomen.”
Case history -
A 21 year old male patient resident of Nalgonda district, waiter by occupation belonging to lower middle class socioeconomic status presented to the hospital with the chief complaints of vomiting since 5 days, loose stools and pain abdomen since 2 days.
Patient was apparently doing well until 5 days ago when he started to have recurrent episodes of vomiting (4-5 times a day) after consuming fried rice the previous night but none of the family members had similar complaints. Non projectile, watery in consistency, containing food particles and non blood tinged. Gradually the episodes of vomiting started to increase upto a level of 8 times per day for the past few days. His appetite was also reduced markedly.
Patient also complains of chest discomfort after having food and while sleeping.
Since 2 days he has been passing frequent episodes of loose watery stools (6 times a day) which were yellow in colour without any mucus and blood.
Since 2 days he has been suffering from pain abdomen in the umbilical region which was sudden in onset and now he has burning sensation in the epigastric region without any aggravating and relieving factors. Urinary output was normal.
No h/o of fever, loss of weight, haematemesis, abdominal distension, pedal edema.
No h/o jaundice, yellow urine, tenesmus.
No h/o travelling and had no other medical illnesses previously.
No similar complaints in the past.
Patient had no known history to food and medications.
Family history not significant.
Personal history - mixed diet, adequate sleep, no addictions, bowel and bladder movements are irregular.
General examination- Patient was conscious, coherent and cooperative. He’s well oriented to time, place and person.
Patient appears to be less active, weak and lethargic.
Vitals - pulse rate 96 bpm
Rr - 15 cycles per minute
Bp - 130/90 mm of hg
Temp Afebrile
CVS - S1 and s2 heard
Per abdominal examination -
Inspection - scaphoid abdomen, no scars, swellings and pigmentation of skin with inverted umbilicus.
No local rise in temperature.
Tenderness in the right epigastric and the left hypochondriac regions on palpation.
Tympanic note on percussion.
Bowel sounds + on auscultation.
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