A CASE OF DIARRHOEA AND VOMITING PRESENTED IN SUMMER 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 a diagnosis and providing treatment best to
our skills and wisdom.
A 50yr old patient who is a housewife presented to the casualty with complaints of loose motions and vomitting .
Date of Admission: 05/06/2023
CHIEF COMPLAINTS
➤ Loose stools (watery) : 5-10 episodes since Sunday .
➤ 1 episode of vomitting.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 5 days ago . Then she developed loose motions . She had 10 episodes of loose stools which were watery , non bilious , in small quantity.
She had no c/o abdominal pain .
She also had an episode of vomitting the same night . It was watery , non bilious, contained food particles , non projectile.
She developed high fever the same night , which was relieved on taking Tab. Dolo 650 mg .
No c/o SOB , chest pain , palpitations, headache, dizziness .
HISTORY OF PAST ILLNESS
➤ She has h/o Acute CVA (rt upper and lower hemoparesis ) 4 months ago , for which she was given Inj. Tenecteplase/stat dose and recovered within a day .
➤k/c/o diabetes mellitus since 17 yrs .
➤ k/c/o hypertension since 1 yr.
➤ Surgical history: Patient is tubectomised .
DRUG HISTORY
1) Tab. Telmisartan 40mg PO /OD for Hypertension for past 1yr.
2) Tab. Metformin 500mg PO/OD for diabetes since last 17 yrs .
PERSONAL HISTORY
➤Occupation: Housewife
➤Patient is married .
➤Patient is vegetarian (since 3 yrs) and has a normal appetite .
➤Sleep : Regular
➤Bladder movements are normal , bowel movements increased
➤No known allergies .
➤ Addictions : Occasional alcoholic, stopped since 1 yr .
FAMILY HISTORY
Not significant
GENERAL EXAMINATION
➤Pallor : seen
➤Icterus : not seen
➤Cyanosis : not seen
➤Clubbing : not seen
➤Lymphadenopathy : not seen
➤Edema : Not seen
VITALS
➤Afebrile
➤PR : 82 beats per minute
➤BP : 120/80 mm of Hg
➤RR : 16 cycles per minute
➤SpO2 : 97% in room air
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM EXAMINATION
➤s1 and s2 heard
➤Thrills absent.,
➤No cardiac murmurs
RESPIRATORY SYSTEM
➤Normal vesicular breath sounds heard.
➤Bilateral air entry present
➤Trachea is in midline.
ABDOMINAL EXAMINATION
INSPECTION
➤Shape - Scaphoid
➤Equal movements in all the quadrants.
➤No visible pulsation, dilated veins and localized swellings.
PALPATION
➤Liver , spleen not palpable.
➤No tenderness
CENTRAL NERVOUS SYSTEM EXAMINATION
➤Conscious and coherent
➤Speech : Normal
➤No signs of meningeal irritation
➤Cranial Nerves - intact
PROVISIONAL DIAGNOSIS : ACUTE GASTROENTERITIS .
INVESTIGATIONS :
1) USG
