A 80 year old male came to casualty with complaints of diarrhoea and vomiting .

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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.

JANHAVI VIRANI 

ROLL NO 58 

December 1, 2021

CHIEF COMPLAINTS 

A 80 year old male came to casuality on 30/11/21 with chief complaints of 

Diarrhoea  since 1 day 

Vomiting since 1 day 

Spasms in extremities since 5 days 

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 2 years back then he had decreased urine output, following which he was diagnosed with renal failure and was prescribed some medication. 

He suffered 3 episodes of  loose stools , watery in consistency and not associated with blood . 

And 3 episodes of vomiting which is not bilious, non projectile contents are good particals. 

Also has fever since the day he presented to casuality which was high grade ( 102 degree F ) 

PAST HISTORY 

No H/O : 

Hypertension 

Epilepsy 

Tuberculosis 

Asthma 

Diabetes Mellitus 

FAMILY HISTORY 

No significant family history 

PERSONAL HISTORY 

diet - mixed 

Appetite- normal 

Sleep- adequate 

Bowel and bladder- regular 

No known drug and food allergy 

Addictions - smoking ( 1 pack of bidi daily)

GENERAL EXAMINATION 

Patient was conscious, coherent and well oriented to time , place and person 

Moderately built and well nourished 

No pallor, icterus , cyanosis , clubbing , lymphadenopathy, Edema

VITALS and SYSTEMIC EXAMINATION 

INVESTIGATIONS 

RENAL FUNCTION TEST 

Urea : 104 mg/Dl

Creatinine : 2.9 mg/dl 

Sodium: 135 mg/dl 

Chloride : 90 mg/dl

LIVER FUNCTION TEST 

Alkaline phosphate: 137IU/L

ULTRASOUND 

Impression 

Grade 1 fatty liver 

Bilateral grade 1 RPD