A 29 year 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 chityala who is Court employer by occupation came with the chief complaints of loose stools and  pain abdomen since yesterday evening 

HOPI
      Patient was apparently asymptomatic till yesterday evening then he had loose stools (15 episodes) which is  mucoid in consistency associated with pain,blood in stools,fever.
Patient also had c/o pain abdomen which is at umbilical region gradually progressive squeezing type  non radiating not associated with burps regurgitation
     H/O consumption of one day old carrot juice,pastry and some mixture
  He took Tab PAN Tab METROZIL 

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:inaquate
  Bowel and bladder: regular 
  
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 cpm
         BP:130/90 mm Hg
Systemic examination
     CVS:S1 S2 heard  no murmurs
     RS:BAE +
     CNS:no focal neurological deficit 
P/A
     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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