1601006197 LONG CASE

 1601006197 LONG CASE

 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. 

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I've 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 a diagnosis and treatment plan. 

A 65 yr old woman, from narketpally who is house wife ,came to hospital with chief complaints of fever with chills since 8 days and pain abdomen since 6 days, loose stools since 6 days.

History of presenting illness

The patient was apparently asymptomatic 8 days back. Then she developed-

-Fever sudden in onset,low grade,associated with chills and rigors, relieved on medication

-Pain in lower abdomen 6 days ago, sudden onset continuous, cramping/dull aching type, aggravates with food intake.

-Associated with vomiting 2-3/day episodes, non bilious non projectile watery consistency.

-Loose stools 6 days back multiple episodes in large volume watery, no tenesmus, no mucous or blood in stools. 

-History of burning micturition since 4 days high colored urine, no froth/blood.

-No hematemesis/malena.

-No other complaints. 

Past history:

-History of diabetes type2 since 10years

-History of hypertension since 10years

-No history of Tuberculosis , asthma, epilepsy ,thyroid disorders, CAD, stroke.

Treatment history:

 -Diabetes -metformin 500mg+idalgliptin 500mg

-Hypertension - telmisartan-40mg

Personal history 

-Diet mixed.

-Sleep disturbed due to loose stools.

-Appetite decreased.

-Bowel- irregular 

-Bladder- urge incontinenece

-No known allergies

-No alcohol 

-No smoking 

Family history:

 -Not significant 

General examination:

-Patient is conscious,  coherent and cooperative.

Well oriented to time place and person. Moderately built & Well nourished 

-Pallor : present

-No Icterus ,Koilonychia ,Clubbing ,Lymphadenopathy ,Edema.

Vitals

-Temperature afebrile

-Bp: 110/80 mm hg

-Pulse 100bpm

-Respiratory rate 19/min

-Spo2 96%

Systemic examination:

Per Abdominal examination 

 Inspection:

-Generalised distention/fullness is seen.

-Shape- distended 

-Flanks full

-Umbilical inverted

-Movements with respiration-  equal in all quadrants. Rises during inspiration falls during expiration.

-No visible pulsations.

-Skin over abdomen multiple vertical stretch marks, horizontal scars.

Palpation :

-No local rise of temperature. 

-Tenderness - diffuse mainly right illac fossa

Liver,Gall bladder,Spleen impalpable.

Percussion:

-Shifting dullness- not present

-Fluid thrill not present

Auscultation 

-Bowel sound normal 

Other system examination

CVS

-S1 , S2 heard

-Apical impulse 5th intercostal space  lateral to midclavicular line.

-No murmers

Respiratory system

-Bilateral air entry

-Normal vesicular breathsounds

-Bronchial breath sounds heard

-Trachea midline 

CNS      

-Gait normal 

-Sensations normal 

-Cranial nerve normal

-Reflexes preserved

Hemogram 

Renal function tests 

Complete urine examination 

Fasting blood sugar

Urine protien/creatinine ratio

Complete urine examination

Glycated hemoglobin

Injections

Antibiotic cephalosporins- cefixime

Investigations:

Stool examination & culture

Sigmoidoscopy/colonoscopy 

Ultrasound abdomen and xray are rarely suggested. 

Urine analysis 

Renal funtion tests

Urine examination:

Increased  pus cells in urine

Differential diagnosis:

Inflammatory Bowel syndrome 

Food poisoning 

Malabsorption 

Pseudomembranous colitis

Possible Diagnosis 

Acute gastroenteritis