General medicine Short Case

9 Feb 2022

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. 

CHIEF COMPLAINT:- 

A 19 years old male,student by the occupation presented to the opd with the chief complaints of vomitings 2-3 episodes since 3 days, abdominal pain since 3days and loose stools 4-5 episodes since 3days.

HISTORY OF PRESENT ILLNESS:- 

Patient was apparently aymptomatic 3days back. Then he went to the function on one day and ate Mutton and oil rice. From then he developed pain in the abdomen which was sudden in onset, continuous in Nature and pain radiated to the left lower abdomen. vomitings 3-4 episodes per day, non-bilious , non-projectile,food as content. Then went to the local hospital.

PAST HISTORY:- 

History of Hypertension and on regular medication since 2 years .                                                              No history DM,Asthma, epilepsy ,TB,CAD.

FAMILY HISTORY:- Not significant.

PERSONAL HISTORY:

Diet: mixed 

Appetite : normal 

Bowel and bladder : loose stools 

Sleep :adequate

No addictions 

No known allergies. 

GENERAL EXAMINATION:- 

Patient is conscious, coherent, cooperative and well oriented to time and place.

No pallor, cyanosis, icterus, clubbing, generalized lymphadenopathy.

VITALS:- 

Temp: Afebrile

Pulse rate:- 86bpm

Respiratory rate:- 17breaths per min.

B.P:- 110/80 mmhg.

SYSTEMIC EXAMINATION:-  

 CVS-:-

S1 ,S2 sounds heard 

No murmurs 

RESPIRATORY SYSTEM:-

Bilateral air entry normal

No dypnea 

No wheeze 

Position of trachea-central

Vesicular breath sounds heard 

ABDOMEN:-

Shape of abdomen -obese 

Mild tenderness is present 

No palpable mass

No bruit 

CNS:-

Speech -Normal

No neck stiffness

No neurological deficits

INVESTIGATIONS:-   

CBP :-

Hemoglobin -14.7 gm/dl

TLC -10,000cells /cumm

Platelet count -2.14 lakhs 

    

PROVISIONAL DAIGNOSIS:-

Acute Gasteroentiritis

TREATMENT:- 

Inj PAN40 mg IV /stat 

Inj ZOFER4mg IV/stat 

Inj Metronidazole100 ml IV /stat 

Tab Sporlac 2mg tab