A 31year male with nausea ,loose stools and abdominal pain

July 11,2023

Hi,I am K.Nidhi Reddy 5th semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio. 

                      CASE SHEET

CHIEF COMPLAINTS:
A 31year male patient  farmer by occupation resident of lingotam came to the hospital with chief complaint of loose stools since 1day

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic  since 1 day then he consumed outside food(fried rice) after which he developed nausea and loose stools of 20-25 episodes per day cause of abdominal pain 
Loose stools of large quantity and non foul smelling
Fever since 1day not associated with chills and rigor, high grade and intermittent
No history of cold,cough ,sob ,throat pain,chest pain,

PAST HISTORY:
N/k/c/o diabetes, hypertension, CAD,tuberculosis, epilepsy

PERSONAL HISTORY:

married 
Appetite - normal
Diet - mixed
Bowl movement - irregular
Micturition -normal
Sleep- normal
No allergies
addictions alcohol - occastional
Smoked 2yrs back occasionally 

FAMILIES HISTORY:

Father and mother- diabetes

GENERAL EXAMINATION:

Pt was conscious, coherent and cooperative 
Moderately built and nourished 
Pallor- absent
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Pedal oedema- Absent

Vitals:

Temperature : 101F
Pulse rate : 64/min
Respiratory rate : 16 per minute 
Blood pressure : 120/70 mm of Hg
sPO2 : 96% 

Systemic Examination 
Cardiovascular System-
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System 
 no dyspnea 
No wheezing
central trachea
vesicular breath sounds

Abdomen
Obese shaped abdomen 
 No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds -yes
CNS
Patient was conscious
Normal speech

Reflexs               
                       Right.  Left
Biceps.              +2.   +2
Triceps.             +2    +2
Supinator.         +1    +1
Knee.                 +2.   +2
Ankle.                 +2.   +2

INVESTIGATION:

USG

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