A 65 yr old male with chief complaints of fever, vomiting and loose stools
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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.
CHIEF COMPLAINTS :
A 65yr old male Patient driver by occupation and resident of Nalgonda came to casuality with chief complaints of fever since 4 days, loose stools since 3 days and vomiting on day 1 and 2 of illness.
HISTORY OF PRESENTING ILLNESS:
patient was apparently asymptomatic 5days back. Then he developed low grade fever intermittent type,not associated with chills/ rigor, cold and cough relieved on medication.
On day 1 of illness he also complaints of an episode of vomiting after postural syncope and total 4 episodes , food particles as content and watery, non bilious, and non projectile .
On day 2 he also complaint of loose stools , 2- 3 episodes/day , greenish in colour, watery, foul smelling, and 100-200ml in quantity and associated with abdominal pain ( squeezing type) in right hypochondriac and epigastric region.
No h/o burning micturition, chest pain , palpitations.
PAST HISTORY:
K/C/O Hypertension since 8yrs on medication Tab.Amlodipine 5mg & tab.Atenelol 50mg
Also a k/c/o diabetes since 8yrs and on medication: Tab.metformin 500mg /po/od
He also had complaints of breathlessness 5months back (h/o copd? ) and uses inhaler .
No h/o TB, epilepsy and thyroid disorders.
FAMILY HISTORY:
not significant
PERSONAL HISTORY:
Pt takes mixed diet. His appetite was decreased and sleep adequate . Bladder movements are regular and complaints of loose stools.
Addictions: alcohol - regular ( 35 yrs ago toddy) Betel leaf ( pan).
GENERAL EXAMINATION:
Pt was conscious, coherent and cooperative.
Well oriented to time, place and person.
Pt was moderately built and nourished.
No h/o pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.
SYSTEMIC EXAMINATION:
CVS: S1,S2 heard. No murmurs.
RS: trachea - central
Normal vesicular breath sounds heard
Abdomen:
Shape - distended
Tenderness at right hypochondriac and epigastric region
No palpable mass
Umbilicus centre and everted.
No free fluid, bruits.
Liver palpable (? Hepatomegaly)
Spleen not palpable
Bowel sounds heard
CNS:
Pt is conscious with normal speech.
No neck stiff, kerning's sign negative.
Power: Rt. Lt
U/L. 5/5. 4/5
L/L. 5/5. 5/5
Glasgow coma scale: 15/15. E4V5M6
Reflexes: Rt. Lt
Biceps + +
Triceps + +
Supinator + +
Knee + +
Ankle + +
Cerebellar signs:
No Finger nose in - coordination
No knee- heel incoordination
Gait: normal
Skin:
hypo pigmented patches a/w itching present
PROVISIONAL DIAGNOSIS:
Acute gastroenteritis?
INVESTIGATIONS:
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