pyrexia with acute diarrhoea
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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
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