A 37 year old male came to causality with complaints of abdominal pain, diarrhoea and fever

37 years old male patient came to casualty with complaints of  abdominal pain, diarrhoea and fever.

7 July 2023

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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.                                          10/7/23

7/7/23.

This is the case of 37 year old male security guard by occupation resident of narketpally. 

CHIEF COMPLAINTS : 

Cold , Fever with abdominal pain and loose motions since morning 8:00 am. 

HISTORY OF PRESENTING ILLNESS :

Patient was apparently asymptomatic 4 days ago. He then developed cold followed by fever associated with chills and rigor. 

No aggrevating and releiving factors. 

He complained of  loose stools 10 - 12 episodes  from morning. 

Watery in consistency, non foul smelling, non blood stained. 

Complained of nausea, pain in abdomen, diffuse, pricking type of pain. 

Past history:

No other complaints of SOB, orthopnea, PND, chest pain, palpitations. 

No complaints of giddiness. 

N/K/C/O  hypertension, diabetes mellitus, thyroid disorders, asthma, epilepsy. 

FAMILY HISTORY:

No family history

Personal history:

Mixed diet

Normal appetite

Adequate sleep

Regular bowl movements

Normal bladder movements

Occasional consumption of alcohol

No history of smoking and chewing of tobacco

GENERAL EXAMINATION:

Prior consent was taken and patient was examined in a well lit room.

Patient was conscious, coherent and cooperative.

No pallor ,icterus, clubbing ,cyanosis.

No generalised lymphadenopathy and bipedal edema. 

VITALS :

Temperature- 104°F

BP-130/80

PR- 96bpm

RR-20cpm/min

Spo2-98%

GRBS-111mg%

SYSTEMIC EXAMINATION:

RS: Bilateral chest and air entry

CVS: S1,S2 positive

PA: soft, no tenderness

CNS : NF NB

Sensory and motor system normal

Investigations:

PROVISIONAL DIAGNOSIS:

Acute gastroenteritis.