Sri Nithya

M. Sri Nithya MBBS 9th semester R oll no: 75      This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs 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, and come up with diagnosis .   42 year old male complaining of abdominal distension since 4 days, lethargy,loss of appetite and not passing stools and urine since 2 days. Following is a brief about the case,

60 year old female daily wage labourer by occupation came with the complaints of loose stools and vomiting since 3 days and no urine output since two days . HOPI:  Patient is a daily wage labourer since 15 years. Seven days ago she has history of consumption of mutton. Later after 4 days patient came with the complaints of loose stools 5 -6 episodes/ day, watery in consistency,  non mucoid , non bloodstained,non foul smelling since 3 days.  Complaints of vomitings 4-5 episodes bilious , non projectile,  food as content. There is also no urine output since 2 days. No h/o pain abdomen,fever , burning, micturition, cough, cold, Sob PAST HISTORY : N/k/c/o of Dm, HTN, CAD , TB, BA, Epilepsy.  No previous hospital admissions.  Personal history Appetite- normal Diet -mixed  bowel and bladder - increased bowel movements and no urine output Sleep- disturbed Addictions- no No known allergies for food or drugs. Family history No similar complaints in the family. No significant family history. Gen