Final Practical Examination -Short Case

 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:-

19 years old male boy came to Opd with chief complaints of pain in abdomen since 3 days  ,loose stools since 3 days and vomiting since 1 day 

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 3days back then he developed pain in abdomen,sudden in onset , continuous,c colicky in nature,and pain is radiated to left lower abdomen.pain gets aggravated during defecation,associated with vomiting ,non bilious,non projectile ,food as content .

History of loose stools since 3 days,5 to 6 episodes per day ,watery stools.

History of intake of meat 3 days back in Function.

 

Past history :-

No history of similar complaints in the past 

Not a known case of diabetic , Hypertension,asthma ,epilepsy .

Personal history:-

Diet -mixed

Apetite-Normal

Bowel and bladder movements-regular

Sleep -adequate

Family history:-

No relevant family history

GENERAL EXAMINATION:-

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

Well built 

No pallor , icterus,cyanosis,clubbing,lymphadenopathy

VITALS:-

Temperature-afebrile

Respiratory rate-18 cycles /min

Pulse rate-76beats /min 

Blood pressure-130/80 mm Hg 

Spo2 -99%on RA 

SYSTEMIC EXAMINATION:-

CVS-:-

S1 ,S2 sounds heard 

No murmurs 

RESPIRATORY SYSTEM:-

Bilateral air entry normal

No dyspnea

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 DIAGNOSIS:-

?Acute Gastroenteritis

TREATMENT:-

Inj PAN40 mg IV /stat 

Inj ZOFER4mg IV/stat 

Inj Metronidazole100 ml IV /stat 

Tab Sporlac 2  tab