General Medicine - 16
A 70 YEAR OLD FEMALE CAME WITH LOOSE STOOLS SINCE 3 DAYS
Fever chart:
ECG:
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-centred online learning portfolio and your valuable comments on 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.
CASE SHEET:
Chief complaints:
A 70 year old female, hailing from chityal, housewife by occupation, came with chief complaints of :
- irrelevant talk since 3 days
- loose stools since 3 days
- abdominal pain since 3 days
History of present illness:
The patient was apparently asymptomatic
Personal history:
Diet: Mixed
Bowel : irregular
Micturition: normal
Appetite: decreased
Habits: nil
No history of allergy, asthma, tuberculosis, coronary artery disease.
Family history:
Insignificant
GENERAL EXAMINATION:
No Pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
Mild dehydration
VITALS:
Temperature: 98.2 F
Pulse: 104 beats per minute, irregular
Respiratory rate: 17 cycles per minute
Blood pressure: 100/80 mm of Hg
SPO2: 96%
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
murmurs: systolic murmur
Cardiac sounds: S1, S2 heard
Respiratory system:
dyspnea present
No wheezing
Breath sounds heard: vesicular
Abdomen:
Shape of abdomen: scaphoid
No tenderness
No Palpable mass
Non palpable liver
No Palpable spleen
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious
Speech: normal
Finger-nose in coordination: no
Knee-heel in coordination: no
Investigations:
Fever chart:
ECG:
Provisional Diagnosis:
Altered sensorium under evaluation.
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