A 59 year old male patient e log

E-LOG GENERAL MEDICINE

Hi, This is K.Srinija , a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

A 59 year old male resident of Munuguru roadside textile seller came to OPD

CHIEF COMPLAINTS :

Loose stools since 1 day

Fever with chills and rigor

5 episode of vomitings since 1 day

HISTORY OF PRESENT ILLNESS :

- Patient was apparently normal 1 day ago

- Since the previous night of admission he had several episodes of loose stools - yellow coloured,large volume watery,not blood stained,non foul smelling and could not sleep thorough out the night.

- Also then developed a high grade fever with chills and rigor

- The next day he also several episodes of loose stools (more than 20 episodes throughout the day) and also had about 5 episodes of vomitings

- Then he went to local hospital and had fluid infusion then came to our hospital

Past History of similar complaints: He had same complaints about 3 years back

HISTORY OF PAST ILLNESS :

- 3 years ago he had back pain and lower limb pain for which he got some Othropedic treatment in our hospital - the got relieved on medication,

- he also diagnosed DM during the same visit ,took Metformin for 3 months and advised to maintain a strict diet.

- Not known case of HTN, epilepsy,asthma ,CAD

No Surgical history

FAMILY HISTORY : Nil significant

PERSONEL HISTORY :

Married

Occupation: textile vender

Diet: Mixed

Appetite: Normal

Bowels movements - Increased

Micturation: normal

Known Allergies: No

Addictions :No

GENERAL EXAMINATION :

No Pallor,icterus , cyanosis, clubbing , lymphadenopathy, pedal edema

VITALS :

Temperature - 101.1 F

BP:-100/70mmHg ,

PR:- 117 bpm,

RR- 21 cpm,

Spo2:-96%

GRBS:136mg/dl

SYSTEMIC EXAMINATION :

CARDIOVASCULAR SYSTEM

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No

RESPIRATORY SYSTEM

Dyspnoea:No

Wheeze: No

Position of trachea: Central

Breath sounds: Vesicular

Adventitious sounds : No

ABDOMEN

Shape - Scaphoid

No tenderness, palpable mass, No Fluid

No bruits

Liver not palpable

Spleen not palpable

Bowel sounds No

CNS Examination

Conscious coherent cooperative

Speech normal

No signs of meningitis

Cranial nerves, motor system, sensory system Normal

INVESTIGATIONS :

2/9/22-

3/9/22 -

4/9/22-

PROVISIONAL DIAGNOSIS :

Acute gastroentiritis

TREATMENT :

Comments

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