A 59 year old male came with loose stools, fever...

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I have been given this case 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.

A 59 year old male resident of Munuguru roadside textile seller came to OPD

 CHIEF COMPLAINTS :

Loose stools since 1 day 

Fever with chills and rigor 

5 episode of vomitings since 1 day

HISTORY OF PRESENT ILLNESS :

- Patient was apparently normal 1 day ago

- Since the previous night of admission he had several episodes of loose stools - yellow coloured,large volume watery,not blood stained,non foul smelling and could not sleep thorough out the night.   

- Also then developed a high grade fever with chills and rigor 

- The next day he also several episodes of loose stools (more than 20 episodes throughout the day) and also had about 5 episodes of vomitings 

- Then he went to local hospital and had fluid infusion then came to our hospital 

Past History of similar complaints: He had same complaints about 3 years back

HISTORY OF PAST ILLNESS :

- 3 years ago he had back pain and lower limb pain for which he got some Orthopaedic treatment in our hospital - the got relieved on medication,

- he also diagnosed DM during the same visit ,took Metformin for 3 months and advised to maintain a strict diet.

- Not known case of HTN, epilepsy,asthma ,CAD

No Surgical history 

FAMILY HISTORY : Nil significant

PERSONEL HISTORY :

Married

Occupation: textile vender 

Diet: Mixed 

Appetite: Normal

Bowels movements - Increased 

Micturation: normal 

Known Allergies: No

Addictions :No

GENERAL EXAMINATION :

No Pallor,icterus , cyanosis, clubbing , lymphadenopathy, pedal edema 

VITALS :

Temperature - 101.1 F

BP:-100/70mmHg ,

PR:- 117 bpm,

RR- 21 cpm, 

Spo2:-96%

GRBS:136mg/dl

SYSTEMIC EXAMINATION :

CARDIOVASCULAR SYSTEM

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No

RESPIRATORY SYSTEM

Dyspnoea:No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Adventitious sounds : No

ABDOMEN

Shape - Scaphoid

No tenderness, palpable mass, No Fluid

No bruits 

Liver not palpable

Spleen not palpable

Bowel sounds No

CNS Examination

Conscious coherent cooperative

Speech normal

No signs of meningitis

Cranial nerves, motor system, sensory system Normal

INVESTIGATIONS :

2/9/22-

3/9/22 -

4/9/22-

PROVISIONAL DIAGNOSIS :

Acute gastroentiritis

TREATMENT :