A 65 YEAR OLD FEMALE PRESENTED WITH FEVER,PAIN ABDOMEN, VOMITINGS,LOOSE STOOLS

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 




Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome."
I've 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. 

CASE:
A 65 year old female with fever,pain abdomen and loose stools.

Chief Complaints :

A 65 yr old woman resident of nalgonda ,a house wife, came with chief complaints of 
-fever, pain abdomen, vomiting & loose stools

History of presenting illness:

The patient was apparently asymptomatic 1 week back and then developed


-Fever: high grade, intermittent, associated with chills & rigors, relieved with medication
-Lower Abdominal pain : sudden in onset, continuous dull aching/cramping, aggravated with food intake
-vomiting 2-3 episodes/day: non bilious, non projectile, watery with food particles
-Loose stools multiple episodes in large volume watery, no tenesmus, no mucous or blood in stools.

Past history:
History of similar compliant two months back which were relieved on medication.
History of diabetes type-2 since 10years and on regular medication
History of hypertension since 10years and on regular medication
No history of epilepsy/asthma/siezures.

Treatment history:

 Diabetes -metformin 500mg+idalgliptin 500mg

Hypertension - telmisartan-40mg

Personal history:

Diet: mixed

Appetite: decreased

Bowel movements :irregular 

Bladder : regular

No known allergies

No addictions 

Family history:

Not significant 

General examination:

Patient is conscious, coherent and cooperative.

Well oriented to time place and person, moderately built,Well nourished 

Pallor : present,Icterus - absent,Cyanosis -absent,Koilonychia -absent,Clubbing - absent,Lymphadenopathy - absent,Edema : facial puffiness present

Vitals:

Temperature: 98.5°c afebrile
BP: 120/80 mm hg
Pulse: 110/ min
Respiratory rate :26/min
SpO2 :96% at room air



Systemic examination:

ABDOMEN
 -Inspection:

Shape- distended ,Flanks full

Umblicus: inverted

Movements with respiration- equal in all quadrants.

Skin over abdomen: multiple vertical and horizontal striae

-Palpation :

Tenderness - diffuse mainly right illac fossa

Liver impalpable

Gall bladder impalpable

Spleen impalpable 

-Percussion:

Shifting dullness- not present

Fluid thrill not present



-Auscultation 

Bowel sound heard



Other system examination



CVS-S1 , S2 normal
Apical impulse 5th intercostal space 2cm later to midclavicular line.
No murmurs

 Respiratory system-Normal vesicular breathsounds,Bronchial breath sounds heard,Trachea midline 

CNS      
Cranial nerve examination : normal
Reflexes : normal

CHEST XRAY:



HEMOGRAM



RENAL FUNCTION TEST

COMPLETE URINE EXAMINATION (CUE)

FASTING BLOOD SUGAR(FBS)


USG REPORT


URINE PROTEIN/CREATININE RATIO

RENAL FUNCTION TEST recent

CUE- 2nd Time

HbA1c



provisional Diagnosis:
Acute gastroenteritis

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