A 22 YEAR OLD MALE WITH C/O DIARRHEA AND PAIN ABDOMEN
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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 treatment plan.
CASE DISCUSSION:
A 22 year old male came with chief complaint of
- Vomitings since 3 days
- Loose stools since 3 days
- Pain abdomen since 2 days
HOPI:
Pt was apparently assymptomatic 3 days back then developed vomitings 10 episodes per day which contained food contents and was associated with nausea. Loose stools 10 episodes on first day and 4-5 episodes on second day which were watery in consistency, non sticky, non foul smelling, non blood stained. Diffuse pain abdomen non radiating.
PAST HISTORY:
No similar complaints in the past
Not a k/c/o DM,htn,tb,asthma,epilepsy
3 yrs back patient developed fever was diagnosed as typhoid
3 months back patient developed fever was diagnosed as dengue fever
PERSONAL HISTORY:
He is a student
Consumes vegetarian diet
Appetite reduced
Bowel n bladder regular
Sleep disturbed because of pain
Addictions: Nil
FAMILY HISTORY:
No similar complaints in family
CLINICAL IMAGES:
GENERAL EXAMINATION:
Pt is conscious, coherent and cooperative
Moderately built and nourished.
On admission:
BP:126/90mmhg
PR:76bpm
RR:24cpm
SPO2: 99% on RA
GRBS: 92mg/dl
SYSTEMIC EXAMINATION:
CVS: S1,S2, +
RS: BAE+
P/A: soft, diffuse tenderness in all 9 quadrants
CNS: NAD
PROVISIONAL DIAGNOSIS:
?PRE RENAL AKI SECONDARY TO ACUTE GE
Day 2
S:
Rt and lt hypochondrial pain with lower back pain
O:
Pt is c/c/c
BP: 160/110 mmhg
PR:90bpm
CVS- S1,S2 heard
RS- BAE+
P/A soft, tender at RT hypochondrial and epigastric region.
CNS- NAD
GRBS- 98mg/dl
Temp- 98f
A:
?PRE RENAL AKI SECONDARY TO ACUTE GE
P:
Tab.vomikind-MD/SOS
Tab.CINOD 5 mg/PO/OD if BP > 140 mmofhg
Strict bp monitoring
Strict I/O charting
Temp monitoring
Day 3
S:
Rt and lt hypochondrial pain with lower back pain
O:
Pt is c/c/c
BP: 160/110 mmhg
PR:90bpm
CVS- S1,S2 heard
RS- BAE+
P/A soft, tender at RT hypochondrial and epigastric region.
CNS- NAD
GRBS- 98mg/dl
Temp- 98f
I/O - 2200/1050
A:
?PRE RENAL AKI SECONDARY TO ACUTE GE
P:
Tab.vomikind-MD/SOS
Tab.CINOD 5 mg/PO/OD if BP > 140 mmofhg
Strict bp monitoring
Strict I/O charting
Temp monitoring
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