irritable bowel syndrome

GENERAL MEDICINE CASE PRESENTATION

CASE SCENARIO 

28/JUNE/2022


Pt aged 28 years female house wife came to opd with chief complaints of loose stools since 30 days associated with abdominal pain and generalised weakness.


HISTORY OF PRESENT ILLNESS 

She was asymptomatic 30 days back ,then she had diarrhea 4 days after visiting her aunt's house.She passes loose stools for 10 times a day and less in quantity and semi solid in consistency assosiated with abdominal pain that releived after passing stools not associated with any blood in stools and associated with generalised weakness.


HISTORY OF PAST ILLNESS 

She visted 3 hospitals for same reason in past 15 days  and used medication which was not relieved.

No H/o DM, HTN, Asthma , epilepsy, TB . 

H/o three C- Sections

No H/o previous medication



TREATMENT HISTORY 

NO history of previous medication 



PERSONAL HISTORY 

Married 

Mixed diet 

Loss of appetite 

Abnormal sleeping patterns with nightmares.

Irregular bowel habits


MENSTRUAL HISTORY

Regular mensus With moderate bleeding.

FAMILY HISTORY 

NO H/O HTN,DM ,EPILEPSY ,TB, ASTHMA



GENERAL EXAMINATION 


    No pallor 

    No icterus 

     No cynosis 

       No lymphadenopathy 

       No clubbing 


PHYSICAL EXAMINATION-:


.temperature-:afibrile 

.pulse rate  -:82/min

.resp rate -:18/min 

.Bp             -:90/70



 SYSTEMIC EXAMINATION 

CVS-; 

        S1,S2 HEARD 

        NO MURMERS 
        
       No thrills

RESPIRATORY SYSTEM-:

         No dyspnea 

          No wheeze 

          Position of trachea -;central 

ABDOMEN-:

        

          Tenderness in right lumber region 

          No palpable mass 

           No palpable spleen and liver 


CNS-:

         Consious, coherent ,cooperative 

         Speech normal

         No neck stiffness

         

SENSORY SYSTEM 

        Pain sensation: present
        Temperature sensation: present
         Touch- +
         Vibration sense: +
         Position sense-+

     PROVISIONAL DIAGNOSIS
  ??Irritable bowel syndrome

TREATMENT HISTORY 

1)TAB SPOROLAC three times in a day.


2)MEVA C Twice daily


3)IVF IONS @100 ml/hour













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