34YR OlD MALE WITH C/O LOOSE STOOLS & VOMITINGS

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Name : Supriya .K ( Intern ) 

Roll Number : 63 

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. 

34YR OLD MALE PATIENT CAME with the Chief complaints of 

Loose stools since yesterday morning 

3 episodes of vomitings  since yesterday

Fever since today afternoon.

Patient was apparently asymptomatic 1day ago ,then he had 10 episodes of loose stools yesterday and 4 episodes today ,large volumes ,watery in consistency,non mucoid ,not blood tinged ; associated with pain abdomen ,which was sudden in onset, non progressive, intermittent, squeezing type of pain ,non radiating, aggravated during episodes of stools ,relieved on medication.

Patient had 3 episodes of vomitings yesterday evening,non bilious ,non projectile ,not blood tinged but has food particles as contents.

Fever since today afternoon low grade , associated with chills and rigors ,relieved by medication .

No H/O outside food intake 

No C/O SOB. , Palpitations, decreased urine output 

Past History: 

N/K/C/O HTN ,DM ,TB ,Epilepsy ,CAD ,Thyroid disorders.

Personal History:

Appetite : Normal 

Diet :  Mixed 

Bowel  movements : increased 

Bladder movements: Regular 

Addictions : occasional alcoholic 

Allergies : No allergies 

General Examination: 

Patient is conscious , coherent, cooperative 

moderately Built, moderately nourished .

Pallor - absent

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy - absent 

Edema - absent 

No signs of Dehydration present --(Sunken eyes -absent ,tongue - moist ,Skin- pinchable)

Vitals : 

BP : 130/ 90 mmHg 

Temp : 100F 

PR : 102bpm 

RR : 18cpm 

GRBS : 118mg/dl 

SPO2 : 98% at RA 

Systemic Examination: 

CVS :  S1,S2-Heard ,No murmurs

RS : BAE + 

CNS : NAD 

PA :  Soft ,Non Tender 

Inspection: 

Shape of abdomen : scaphoid 

Umblicus : central , inverted 

Skin over the abdomen : Normal 

Engorged veins : absent 

No scars ,sinuses .

Palpation: 

all inspectory findings confirmed 

No rise of temperature and tenderness 

No guarding and rigidity 

No hepatomegaly and Splenomegaly 

Percussion : 

Fluid thrills - absent 

Shifting dullness - absent 

Puddle sign - absent 

Auscultation : 

Bowel sounds are heard 

Provisional Diagnosis: 

Acute Gastroenteritis 

Investigations : 

Management: