29 Old male with Pain Abdomen and loose stools

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.
            29 yr old male patient resident of chityalaCourt employer by occupation came with the chief complaints of loose stools and  pain abdomen since  2days

HOPI
      Patient was apparently asymptomatic 2 days back then he had loose stools (15 episodes) which is of low volume mucoid in consistency associated with tenderness, melena,fever.
Patient also had c/o pain abdomen which is at umbilical region gradually progressive squeezing type not associated with belchings ,regurgitation non radiating 
     H/O consumption of one day old carrot juice,pastry and some mixture
  He took Tab PAN Tab METROZIL Tab ELDOPER outside 

Past history
      Not a known case of  DM,HTN,Asthma, epilepsy ,CAD, Thyroid disorders

 Treatment History:not significant 
      

Family History:No significant family history 
   
Personal History
  Diet:mixed
  Appetite:decreased
  Sleep:aquate
  Bowel irregular and bladder: normal
  No addictions 
  
General Physical Examination
  Patient is conscious coherent and cooperative
    Moderately built and moderately nourished
             No pallor,Icterus,cyanosis, clubbing,lymphadenopathy
  
Vitals
         Temperature:98.7 F
         Pulse rate:68beats per minute 
         Respiratory rate:18 C/minute
         BP:130/90 mm Hg
Systemic examination
     CVS:S1 S2 heard  no murmurs
     RS:BAE +
     CNS:no focal neurological deficit 
P/A
On inspection:
shape of abdomen :scaphoid
On palpation 
    Non tender no organomegaly
      


Investigations:
     

  

     
      

   
     



  

Provisional diagnosis
       Acute gastroenteritis secondary to food poisoning.
 Treatment:
  IVF
 Tab SPORLAC p/o BD
 Inj PAN IV/OD
 ORS sachets 1packet per one litre
 (200ml after each stool)
  Monitor vitals 
  Tb OFLOX OZ. P/o BD.
   

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