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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