pyrexia with acute diarrhoea

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.

K.Medha Reddy, intern 

Roll No: 61

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.

CASE:

C/O fever since 6days

C/O lower abdominal pain since 6 days

HOPI: Patient was apparently assymptomatic 6 days back, then she developed pain in left lower abdomen, sudden in onset, gradually progressive, no aggravating and reliving factors.

H/O fever since 6 days, High grade, continuous with chills and rigors.

H/O nausea+ 

H/O vomitings+ 2 episodes 4days back, non bilious, non projectile, with food as content

H/O loose stools - 2 episodes per day

No H/O burning micturition

For the above complaints, conservative treatment was given at an outside hospital.

Past History:

No H/O similar complaints in the past

K/C/O HTN is medication

Not a K/C/O DM,TB, Epilepsy, Asthma, Thyroid disorders 

Personal history:

Appetite: decreased from the past 2 days

Diet: mixed

Bowel habits: regular 

Bladder habits: regular 

Addictions: nil

Family history:

No significant family history

On general examination: 

Pt is c/c/c

No pallor, icterus, cyanosis, clubbing, pedal edema and lymphadenopathy. 

Vitals: 

Temp: 101°F

PR: 119bpm

RR: 24 cpm

BP: 110/60mmHg

Spo2: 89% on RA

GRBS: 95 mg/dl

Systemic examination:

CVS: 

S1 S2 heard, 

no murmurs

RS: 

B/L Air Entry +

Diffuse wheeze +

Crepts: -

P/A: 

Inspection:

Shape: Scaphoid, umbilicus is central and inverted.

All quadrants mining equally with respiration

Palpation:

Soft, no organomegaly

Tenderness + in epigastric region and hypogastric region

Percussion: liver dullness not obliterated

Auscultation:

Bowel sounds+

CNS: 

HMF+

Conscious

GCS: 15/15

Speech: normal

No focal neurologic deficits