57 year old female with diarrhea

This is an 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 patient's 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 the comment box.


57 year old female presented to opd with cheif complaints of
1.fever since 2 days
2.loose stools since 2 days
3.generalized body weakness since 2        days

HOPI

Patient was apparently asymptomatic 2 days back then she had 5 episodes of diarrhea along with 1 fever spike and pain abdomen , the pain abdomen was diffuse the following day she had 2 episodes of vomiting and 4 episodes of diarrhea.
History of consumption of outside food 2 days ago
Patient has no complaint of chest pain , palpitations,headache .
 
The next day she had 8 episodes of diarrhea ,no complaint of pain abdomen

PAST HISTORY 

Patient has hypertension since the last two years
Patient has no history of DM/THYROID/EPILEPSY/
TUBERCULOSIS/ASTHMA

DAILY ROUTINE

Patient wakes up at around 6 in the morning and helps with household chores . patient has breakfast around 8 am and usually consumes fruit. Patient has lunch at around 1:30 pm and consumes curd rice along with a banana ,due to digestive issues the patient usually avoids spicy food.
Dinner is had around 8pm and consists the same as lunch.patient goes to bed at around 10 pm. 

Patient stays at home for most of day as she is retired 

General examination

Pallor: absent
Icterus:absent
Clubbing: absent
Cyanosis: absent
Lymphadenopathy: absent
Edema: absent

Vitals:

Temp: afebrile on time of examination 
BP 140/45
Heart rate 110 bpm
Resp Rate 16/min 

Abdominal examination:
Abdomen is soft and non tender
No organomegaly
No shifting dullness
No fluid thrill
Bowel sounds heard
Respiratory examination

I: Chest bilaterally symmetrical, all quadrants
moves equally with respiration
P: Trachea central, chest expansion normal
P: Resonant
A: B/l equal air entry, no added sounds heard

CVS examination:

I: No precordial buldge. Apical impulse
visible, Venous prominence
P: Apical impulse, No palpebral pulsation.
thrill
A: S1 S2, No murmur

INVESTIGATION

2-D echo
Ultrasound

Differential diagnosis 
 Acute gastroenteritis
(Greenish stool could indicate that you have a bacterial infection (salmonella or E. coli, for example), viral infection (norovirus) or a parasite (Giardia) causing a rapid transit “gush” of unabsorbed bile)

Comments

Post a Comment

Popular posts from this blog

45 year old male with weakness of upper and lower limbs and joint pains since 1 month

Image
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. 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 . Cheif complaints: A 45 year old male construction worker by occupation came to the op with chief complaints of weakness of left upper and lower limbs since one month  Tingling sensation in left upper and lowe
Read more

77M WITH PARASTHESIA ALL OVER BODY

Image
A 77year old male came to the opd with chief complaints of pricking sensations all over the body since 1 year.  COURSE OF EVENTS : Patient is a farmer by occupation. He is uneducated and started working in the farms since his teenage. At the age of 25 years he got married(consanguineous marriage).After 2 years he lost his father due to? Seizure like activity.  After 2-3 months suddenly he experienced unknown fear, palpitations, chest heaviness, tingling sensations. He experienced tingling sensations initially over the head later extending on to the face, trunk and his limbs. He reports that he ran away 2-3 times from his home and he was found and brought back by his mother . When enquired why he ran away from his home he said that due to unknown fear, anxiety and palpitations he didn't like to stay back at home.( He reported that he didn't have any problem with his mother and she took good care of him).  He was not able to cope up from the death of his father. So his mother too
Read more

34 year old female with itching and red lesions ( CASE TAKEN IN MARCH)

Image
THIS IS AN 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT." 34 year old female  ,homemaker  by occupation comes to casualty with complaint of fever ,shortness of breath and dry cough  ,loss of appetite since 7 days. Chief  complaint high grade fever and cough with yellow colored  sputum since 5 days bilateral pedal edema (pitting type) since 5 days difficulty in breathing even at rest  (grade 4) since 5 days Generalized weakness since 5 days History of presenting illness The patient was apparently asymptomatic 1 yr back when she developed b/l knee joint pain and itching in upper aspect of chest and neck.The pain was insidious in onset and gradually progressive a
Read more