gm case


This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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
CHIEF COMPLAINTS :
   A 45 yr old male c/o fever since 5 days, abdominal pain , loose stools and vomitings since yesterday.
HISTORY OF PRESENT ILLNESS:
patient was apparently asymptomatic 5 days ago and then developed fever, which is low grade, not associated with chills and rigors and relieved on medication. He complains of diffuse pain abdomen since 11th October morning. He had 3-4 episodes of vomiting on the same day evening, food particles as content and non- bilious in nature .He had loose stools since evening the same day, which is of 5 -6 episodes and so he went to local hospital. He developed weakness of both upper and lower limbs and found to be having low potassium, correction was done and the weakness got improved. He now came with c/o abdominal pain , vomiting and loose stools.
PAST HISTORY
Not a k/c/o DM, Hypertension, Asthma, epilepsy, CAD, CKD. 
He went for a General checkup 6yrs ago, where he was diagnosed as HIV positive. He was on ART . 
He met with an accident 3yrs ago and got Right ankle fracture, followed by malunion 
FAMILY HISTORY 
No significant family history.
PERSONAL HISTORY:
Diet- mixed
Appetite-normal
Bowel and bladder movements- regular.
Addictions- occasional toddy consumption.
Allergies- none
General examination:
Patient is conscious, coherent and cooperative. Well oriented to time, place and person.
Moderately built and moderately nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
Vitals:
Temp- 98°F
BP-110/70MMHG
RR-18CPM
PR- 100BPM.
GRBS-155 mg/dl.
Spo2 - 100%
Systemic Examination:
CVS: S1,S2 Heard
      No Murmurs 
RS: B/L Normal Vesicular Breath Sounds Heard. 
Abdomen 
Shape - scaphoid
Abdomen moves equally with respiration. 
Umbilicus inverted
No scars and sinuses present. 
No visible pulsatios , no engorged vein

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