This is 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 patients 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 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
D.Santhosh (Internee)
A 19 yr old male presented with complaints of...
- Vomitings since yesterday,
- Diarrhoea since yesterday
- Headache since morning
History of presenting Illness :
- Patient was apparently asymptomatic 1 day back then after consumption of outside food; he developed .....
- Vomitings - 5 episodes, contains food particles, non bilious, non projectile,
- Diarrhoea - 11 episodes , not associated with stomach pain.
- Headache - frontal region, non radiating, no photophobia
- No H/o burning micturition.
- No H/o fever, hemetemesis.
Past history :
Not a known case of HTN, DM, TB, Asthma Epilepsy.
Personal history :
Diet - mixed,
Appetite - Decreased
Sleep - Adequate
Bowel movements - Increased
Family history :
Insignificant
General examination :
Patient is conscious, coherent cooperative and well oriented to time, place and person.
No signs of pallor, icterus, cyanosis ,clubbing, lymphadenopathy and edema
VITALS
Temp - afebrile
PR - 100
BP - 120/80 mm hg
Spo2 - 99 at RA
RR - 16CPM.
Systemic examination :
Cvs :
S1 and S2 heard; no murmurs.
RS :
BAE+ , NVBS present.
P/A :
Soft and non tender
CNS : NO Abnormality detected
INVESTIGATIONS
Hemogram on 11/01/23,
Hb - 17.4 mg/dl
TLC - 9200 /mm3
PLT - 2.6 lakh
on 14/01/23,
Hb - 15.9 mg/dl
TLC - 5200 /mm3
PLT - 1.7 lakh
ECG : Normal sinus rhythm
USG ABDOMEN : Mild central IHBRD
TREATMENT GIVEN :
- Tab TAZIM 200 mg PO/BD
- Tab METROGYL 400 mg PO/TID
- Tab PAN 40mg/BD
- Tab ZOFER 4mg IV/SOS
- Tab BECOZINC PO/OD
- ORS Sachets + 200 ml of water after every episode of vomiting
- Plenty of water intake
PROVISIONAL DIAGNOSIS :
Acute gastroenteritis toxin mediated? anaerobic bacterial?
Follow up
- Tab METROGYL 400mg PO/TID for 2 days
- Tab TAXIM 200mg PO/BD for 2 days
- Tab PAN 40mg PO/BD for 5 days
- Tab BECOZINC PO/OD for 7 days
- Plenty of water intake
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