𝗔 𝟯𝟭 𝗬𝗘𝗔𝗥 𝗢𝗟𝗗 𝗠𝗔𝗟𝗘 𝗪𝗜𝗧𝗛 𝗔𝗖𝗨𝗧𝗘 𝗗𝗜𝗔𝗥𝗥𝗛𝗘𝗔....
This is an online E log book to discuss our patient's de-identified health data shared after taking his guardian's 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 also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome.
No Icterus
No clubbing
No cyanosis
𝐀 𝟑𝟏 𝐲𝐞𝐚𝐫 𝐨𝐥𝐝 𝐦𝐚𝐧 𝐜𝐚𝐦𝐞 𝐭𝐨 𝐜𝐚𝐬𝐮𝐚𝐥𝐢𝐭𝐲 𝐰𝐢𝐭𝐡
CHIEF COMPLAINTS
20 loose stools since 1 day
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic till yesterday night then consumed outside food (fried rice) after which he developed loose stools of 20-25 episodes per day with abdominal pain. Stools were of large quantity, loose in consistency and non-foul smelling.
He also has Fever since 1 day, not associated with chills and rigors. Fever is of High grade, intermittent and not associated with cough, cold, SOB, sore throat.
The patient also complains of burning micturition since 1 day.
No C/O chest pain, palpitations, constipation, decreased urine output, hematuria, pyuria.
DAILY ROUTINE:
Patient is a 31 year old male. He is married and has 3 kids. He is a farmer by occupation. He wakes up at 6am everyday, freshens up and goes to his farm. He comes back home at 8am and has breakfast and returns to farm. He sometimes has his lunch at 1:00pm and the other times he skips it and has a early dinner. He comes back home at 7:00pm and spends time with his family. He eats dinner at 8pm and sleeps at 11:00pm.
PAST HISTORY:
N/K/C/O DM, HYPERTENSION, TB, CVA, CAD, THYROID DISORDERS, BRONCHIAL ASTHMA.
PERSONAL HISTORY:
Diet: Mixed
Sleep: Adequate
Bowel: 20 stools/day since yesterday
Addictions: The patient drinks 1 beer during functions (rarely)
Allergies: Nil
Family history: Not significant
GENERAL EXAMINATION
Patient is examined in a well lit room after taking an informed consent.
He is conscious, coherent and cooperative.
No pallor
No signs of pedal edema and generalized lymphadenopathy.
VITALS:
Temp: 101F
Pulse: 64bpm
RR: 16cpm
Bp: 120/70 mm of hg
Spo2: 96%
INVESTIGATIONS:
HEMOGRAM
Hemoglobin: 14.5gm/dl
Total WBC count: 5,300cells/cumm
Neutrophils: 79
Lymphocytes: 11
Eosinophils: 01
Monocytes: 09
Basophils: 00
PCV: 42.4
MCV: 88.3
MCH: 30.2
RDW CV: 11.9
RDW SD: 38.9
RBC count: 4.80
Platelet count: 1.51lakh/cumm
COMPLETE URINE EXAMINATION
Colour: Pale yellow
Appearance: Clear
Reaction: Acidic
Specific gravity: 1.010
Albumin: +
Sugar: Nil
Bile salts: Nil
Bile pigments: Nil
Pus cells: 3-6
Epithelial cells: 2-4
Red blood cells: Nil
Casts: Nil
Crystals: Nil
Amorphous deposits: Absent
Others: Nil
Blood urea:26
Serum Creatinine: 1.0
Hbs Ag Rapid: Negative
HIV 1/2 Rapid test: Non reactive
LIVER FUNCTION TEST
Direct bilirubin: 0.24gm/dl
Total bilirubin: 0.86gm/dl
AST: 27 IU/L
ALT: 40 IU/L
Alkaline phosphatase: 113 IU/L
Total protein: 6.4 gm/dl
Albumin: 4.08 gm/dl
A/G Ratio: 1.76
SERUM ELECTROLYTES
Sodium- 141mEq/L
Potassium- 3.8 mEq/L
Chloride- 106 mEq/L
Calcium- 1.16 mmol/L
RENAL FUNCTION TEST
Urea- 20mg/dl
Creatinine- 1.1mg/dl
Uric acid- 4.6mg/dl
Calcium- 9.8
Phosphorus- 2.9
Sodium- 138
Potassium- 3.6
Chloride- 102mEq/l
