This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have 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 diagnosis and treatment plan
CHIEF COMPLIANTS
vomitings since evening 4hrs - 3episodes
Loose stools 2 episodes
HOPI
Patient was apparently asymptomatic 4hours back then developed vomitings 3 episodes food as content non bilious non blood stained non projectile
No h/o outside food intake
No h/o fever
No h/o abdominal pain
No sob
PAST HISTORY
Not a k/c/o htn DM epilepsy Tb asthma
TREATMENT HISTORY
No
PERSONAL HISTORY
appetite normal
Diet mixed
Bowel and bladder regular
Addictions tobacco snuff
FAMILY HISTORY
no
GENERAL EXAMINATION
patient is conscious coherent and cooperative
No pallor icterus clubbing cyanosis lymphadenopathy
Vitals
Temp 98.4F
PR 86 bpm
RR 18 cpm
GRBS 160mg%
SYSTEMIC EXAMINATION
CVS S1 S2 + no murmurs
RESPIRATORY
Trachea central
Normal vesicular breath sounds
ABDOMEN no tenderness
No bruits
Liver not palpable
Spleen not palpable
CNS. Reflexes
Right left
Biceps. +2. +2
Triceps. +2. +2
Supinator. +2. +2
Knee. +2. +2
Ankle. +2. +2
INVESTIGATIONS
05/04/23
HEMOGRAM
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