A 26 year male patient complaints of loose stools
A 26 year male patient complaints of loose stools
21 August 2022
E LOG GENERAL MEDICINE
Hi, I am Naalla Gayathri , 3rd Sem Medical Student.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 box is welcome.”
I've 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.
CHIEF COMPLAINTS:
Complaints of loose stools since 20 days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 months ago , then he developed bilateral flank pain. He also developed loose stools which were insidious in onset with 4-5 episodes per day( 10 days liquid consistency, 10 days hard consistency) and was suffering from generalized body weakness since 3 months, which was not associated with nausea, vomiting, Fever. No blood in stools.
First approached RMP doctor and taken medication.
Liquid consistency stools but on medication it becomes hard consistency.
PAST HISTORY:
He is a known case of DM since 3 years ( on irregular medication stopped taking insulin 7 months ago) .
Horse like gait and right foot drop.
Continuous leg pains and muscle wasting.
No history of hypertension
No history of tuberculosis
No history of epilepsy
Known case of polio
PERSONAL HISTORY-
Diet: mixed
Appetite: Normal
Sleep: adequate
Bowel: increased(sometimes 10 times)
Bladder: normal
FAMILY HISTORY-
No significant family history
GENERAL EXAMINATION:
Patient was conscious coherent and cooperative.
No pallor
No clubbing of fingers
VITAL SIGNS:
Temp: afebrile
Bp: 110/ 70 mmHg
PR: 90bpm
RR: 18 cpm
SYSTEMIC EXAMINATION:
CVS: S1 S2+
CNS: NAD
Lungs: BAE+
GRBS : high
INVESTIGATIONS:
Fever chart
Ketone bodies
Hemogram
Complete urine examination
GRBS
20/08/22
2am: 218mg/dl
7am: 141mg/dl
