55yr Female with c/o vomiting and loose stools

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.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment"
Date of Admission-27-10-2022

55 years old female with chief complaint of vomiting and loose stools since 3day


HISTORY OF PRESENT ILLNESS

Patient is apparently asymptomatic 3months back then she noticed multiple swellings infront of right ear lobule ,low grade fever , intermittent, evening rise in temperature, decreased appetite

Since 3days she had c/o vomiting and loose stools 4-5 episodes non bloody

C/o fever since 3months

C/o breathlessness since 3month

C/o Burning micturition

C/o decreased appetite since 1month 

C/o vomiting after taking food


HISTORY OF PAST ILLNESS 

History of hypertension since 7years

No history of surgery, asthma, TB, CAD, epilepsy, Diabetes mellitus


PERSONAL HISTORY

Married

Occupation:-Farmer

 Decreased appetite

Bowel movement is irregular

Bladder movement is Normal

Diet: Mixed

Sleep : Adequate

No addictions


FAMILY HISTORY

 No history of DM, CAD, Asthma and thyroid disorders in the family


GENERAL EXAMINATION 

Patient is conscious, coherent, co-operative.

There are no signs of icterus, clubbing, pallor, cynosis, lymphadenopathy


VITALS

Temperature- 98.8 °F

Pulse rate- 82bpm

Respiratory rate -18/min

BP- 120/80mmhg

Spo2- 98


SYSTEMIC EXAMINATION:

Cardiovascular System

Thrills- No

Cardiac sounds- S1, S2 heard

Cardiac murmurs -No


Respiratory system

Position of trachea- central

Breath sounds- vesicular

Adventitious sounds- No


ABDOMEN

Shape of abdomen- scaphoid

No tenderness

Palpable mass- No

Hernias orifices- Normal

Free fluid- No

Bruits- No

Liver- Not palpable

Spleen- Not palpable

Bowel sound- Yes


CENTRAL NERVOUS SYSTEM 

Patient is conscious 

Speech- normal

No sign of meningitis 

Motor and sensory system- Normal

Cranial nerves- intact


Provisional diagnosis

Acute viral gastroenteritis


Investigation 
Treatment 





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