Case 1

This is an 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome.

Name : K. Santosh Kumar
Roll no : 52

A 44 yr old woman who is home maker presented to the OPD with the complaints of vomiting the previous day( Thursday) which was non bilious containing food particles. She also complained of 3 to 4  episode of loose stools black coloured (few episodes with red coloured stools)
She gave a history of fever 5 days ago.
She gives a history of pain during defecation since one day.
There is no history of Hematuria, Rash on the body and burning micturition 

History of past illness:
She is a known case of hypertension since 5 months on medication with Telmisartan 20 mg OD
She had an episodes of pedal edema and decreased urine output for which she takes Tab DYTOR plus 
She had a history of hemorrhoids 5 months ago 


Personal history
Appetite : Normal 
Diet : Mixed
Bowl and bladder habits are regular 
Sleep is adequate 
No addictions
No history of food and drug allergies 

General examination
Pallor ; present 
No icterus, cyanosis, clubbing Lymphadenopathy

Vitals
GRBS :141mg %
Spo2 :98 % @ room air 
Pulse : 110 beats per minute 
Respiratory rate : 22 cpm

Systemic examination 
CVS : S1 s2 Heard 
RS : No wheeze, No dyspnea, BAE+ , normal vesicular breath sounds heard, position of trachea is Central 
Per Abdomen : scaphoid in shape, No tenderness , Hernial orifices are Normal, No free fluid and no bruits. Liver and spleen are not palpable. On auscultation bowel sounds are Heard.
CNS :. Higher motor and sensory functions are normal 

Per Rectal Examination 
External anal spinchter is normal 
Tone of spinchter is increased
External skin tag present at 12'0 clock position.
No palpable mass
Rectum is loaded with stools 
Gloves stained with blackish red stools 

Provisional Diagnosis 
Viarl pyrexia with thrombocytopenia with blood stools secondary to DYSENTERY ??/ HEMORRHOIDS


Investigations

ECG

Blood for MP strip test
Complete urine test 


APTT

Prothrombin time 
Blood grouping and RH typing 

Daily progress
Medications 


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