A 37 year old male came to causality with complaints of abdominal pain, diarrhoea and fever.
This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim to solve the patient’s clinical problem with collective current best evident based input.
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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.
This is the case of 37 year old male security guard by occupation resident of narketpally.
CHIEF COMPLAINTS :
Cold , Fever with abdominal pain and loose motions since morning 8:00 am.
HISTORY OF PRESENTING ILLNESS :
Patient was apparently asymptomatic 4 days ago. He then developed cold followed by fever associated with chills and rigor.
No aggrevating and releiving factors.
He complained of loose stools 10 - 12 episodes from morning.
Watery in consistency, non foul smelling, non blood stained.
Complained of nausea, pain in abdomen, diffuse, pricking type of pain.
Past history:
No other complaints of SOB, orthopnea, PND, chest pain, palpitations.
No complaints of giddiness.
N/K/C/O hypertension, diabetes mellitus, thyroid disorders, asthma, epilepsy.
FAMILY HISTORY:
No family history
Personal history:
Mixed diet
Normal appetite
Adequate sleep
Regular bowl movements
Normal bladder movements
Occasional consumption of alcohol
No history of smoking and chewing of tobacco
GENERAL EXAMINATION:
Prior consent was taken and patient was examined in a well lit room.
Patient was conscious, coherent and cooperative.
No pallor ,icterus, clubbing ,cyanosis.
No generalised lymphadenopathy and bibipedal edema.
Investigations:
VITALS :
Temperature- 104°F
BP-130/80
PR- 96bpm
RR-20cpm/min
Spo2-98%
GRBS-111mg%
SYSTEMIC EXAMINATION:
RS: Bilateral chest and air entry
CVS: S1,S2 positive
PA: soft, no tenderness
CNS : NF NB
Sensory and motor system normal
Investigations:
PROVISIONAL DIAGNOSIS:
Acute gastroenteritis
