26 years old man to hospital with loose stools and leg pain radiating from knee to foot






 Hi, I am Niteesh Gangina (roll no :81)3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

Chief complaints 

The patient came to the hospital 4 days back with loose stools since 28 days.leg pain radiating from knee to foot.with excessive hunger and thirst .also from generalised weakness

History of present illness

Patient was apparently okay 20days ago and then he developed loose stools (4-5episodes per day)and gradually developed generalised weakness.

History of past illness

Had an appendectomy 15 years back.

Diabetes mellitus since 3 years.(stopped insulin 7 months back)

Personal history 

Occupation daily labourer stopped after getting diabetes

Diet:mixed

Bowels normal

Appetite:normal

Micturation irregular

Sleep:normal

No known allergies 

Habits:alcohol taken regularly 


FAMILY HISTORY 

 Diabetes - No

Hypertension -No

Heart disease - No

Stroke - No 

Concern - No

Tuberculosis-no

Asthma - No

General examination 

No pallor 

No icterus 

No cyanosis 

No clubbing of fingers

No lymphadenopathy 

No pedal odema 





SYSTEMATIC EXAMINATION:

B. CARDIO VASCULAR SYSTEM

1. Thrills No 

2. Cardiac Sounds

3. Cardiac murmurs No 

C. RESPIRATORY SYSTEM

1. Dyspnoea - No

2. Wheeze - No 

3. Position of Trachea - Central

4. Breath Sounds - Vesicular

5. Adventilious Sounds - No

D. ABDOMEN

1. Shape of abdomen - Scaphoid 

2. Tenderness - No

3. Palpable mass - No 

4. Hernial Orifices Normal 

5. Free Fluid No 

6. Bruits No 

7. Liver - Not palpable

8. Spleen - Not palpable 

9. Bowel sounds -Yes


Investigation 






Treatment
28/8/22
doxycycline 
Pantop
Dolo
Citrixine
Atorvas

29/08/22
Doxycycline 
Pantop
Dolo
Citrizine
Atorvas
Opineuron


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