20F with Viral gastroenteritis

 30 October 2023

Hi ,I am Ananya Nayak, 6th sem medical student. This is an online elog book to discuss our patient’s health data after taking her consent.This also reflects my patient centered online learning portfolio.

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 based evidence based inputs.

A 20 yr old female who is a student and resident of Nalgonda came to the OPD with chief complaints of fever since 1 day , loose stools since 1 day and pain abdomen since 1 day

HISTORY OF PRESENT ILLNESS-

Patient was apparently asymptomatic 2daysback.Then she developed fever which was sudden in onset,high grade,associated with chills and rigor,relieved on medications. No diurnal variation is seen.Not associated with cough and cold.

C/o loose stools which was watery in consistency, non blood stained, non-foul smelling ,4-6 episodes per day.It was associated with 

Pain abdomen-tenderness was present in left lumbar and suprapubic region.

H/o nausea present. 

H/O consuming outside food present. 

No H/o burning micturition, 

PAST HISTORY-

N/K/C/O HTN,DM,EPILEPSY, ASTHMA, Thyroid disorders. 

PERSONAL HISTORY-

Diet-mixed

Sleep-inadequate

Bladder movements-normal

Bowel movements-irregular

No addictions 

No known allergies 

FAMILY HISTORY-

No significant family history found

GENERAL EXAMINATION-

Patient is C/C/C.She was well aware of her surroundings.She is well built 

No pallor 

No icterus 

No lymphadenopathy 

No cyanosis 

No clubbing of fingers 

No pedal edema

VITALS-

Temperature-98.2F

BP-110/70 mmHg

RR-16cpm

PR-82 bpm

SpO2-98% RA

GRBS-128 mg/dl

SYSTEMIC EXAMINATION-

CVS-
S1,S2 are heard
No murmurs
Thrills absent

RESPIRATORY EXAMINATION-
Normal vesicular breath sounds are heard.
Bilateral air entry present
Trachea is in midline
No wheeze
No dyspnea

ABDOMEN EXAMINATION-
Inspection
Shape -Elliptical
Equal movements in all quadrants
No visible pulsation and localised swellings. Hernial orifices intact
Umblicus-inverted
Skin over abdomen is normal
Palpation-
Liver,spleen not palpable.
Mild Tenderness present in the left  lumbar region and suprapubic tenderness
Bowel sounds heard.

CNS EXAMINATION-
Conscious
No signs of meningeal irritation.
Speech-normal
Cranial nerves-normal
Gait-normal
Knee heel incoordination-No
Finger nose incoordination-No

TREATMENT-

TAB CEFIXIME 200 mg ×3 days

TAB DOLO 650 mg

TAB CYCLOPAM

TAB PAN-D

ORS SACHETS