This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This E-blog also reflects my patient's centred online learning portfolio. 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 a diagnosis and treatment plan.
Chief complaints:-patient came with chief complaints of fever on 28th June, loose stools since 6 days and vomiting from past 5 days.
History of presenting illness:- Patient was apparently asymptomatic 7 days back then she had 7 to 10 episodes of diarrhoea along with fever spike on 28th June, stools were loose and green in colour and not associated with abdominal pain. Fever was associated with vomiting after consuming food ( 3 to 4 episodes of vomiting) and vomit contained food particles and is not blood stained. Fever not associated with chills and rigor.
She complained that she couldn’t control and didn’t know that she was defecating and also urinating.
History of consumption of outside food 10 days ago for continuously 2 days.
On 29th June she was brought to casualty of Kamineni hospital. Before bringing her to casualty she had 8 episodes of diarrhoea and 2 episodes of vomiting, not associated with abdominal pain.
Fever associated with generalised weakness.
On 30th June she had 3 to 5 episodes of loose stools and mild dehydration.
On 2nd July she had 10 episodes of watery stools with mild dehydration.
On 3rd July she had 2 episodes of loose stools in the morning and 2 episodes in the night.
On 4th July she had no complaints of loose stools, fever.
Daily routine:-Patient wakes up at around 6 in the morning and does household work. patient usually eats breakfast around 8 am and mostly consumes fruits. Patient eats lunch at around 1:30 pm and consumes curd rice along with a banana ,due to digestive issues the patient usually avoids spicy food from past 1 year.
Dinner is consumed around 8pm and usually eat either curd rice or milk or leftover food from lunch. Patient goes to bed at around 10 pm.
Patient stays at home for most of the day as she is retired.
After admitting in hospital she is only consuming idli and Karam podi for all 3 meals.
Past history:-
Patient is a known case of hypertension since two years and she stopped medication from past one year.
Patient had tubectomy done 23 years ago.
Patient has no history of DM,TB, asthma, epilepsy, thyroid abnormalities.
Personal history:-
Diet - mixed
Appetite - decreased
Sleep - adequate
Bowel and bladder movements - irregular
Addictions- nil
No significant family history.
General examination:-Patient is conscious, coherent, uncooperative and well oriented to time, place and personModerately built and moderately nourishment.
Vitals :-
Temp - afebrile on time of examination BP - 140/80 mm/hg
Pulse rate - 120 bpm
Respiratory rate - 16 cycles per minute
Pallor - absentIcterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Oedema - absent
Systemic examination:-
1) abdominal examination:-
Abdomen is soft and non tender
No organomegaly
No shifting dullness
No fluid thrill
Bowel sounds heard
2)Respiratory examination :-
- Chest bilaterally symmetrical, all quadrants
moves equally with respiration.
- Trachea central, chest expansion normal.
- Resonant.
- Bilateral equal air entry, no added sounds heard.
3)CVS examination:-
- No precordial buldge. Apical impulse visible, Venous prominence.
- Apical impulse, No palpebral pulsation.
- S1 S2, No murmur.
4)CNS examination :-
- No focal neurological defects.
- all cranial neves are intact.
Provisional diagnosis:- acute gastroenteritis.
INVESTIGATIONS:-
2D echo:-
Culture report:-
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