Loose stools and Generalised weakness (26 year old man) GM CASE - 5
22nd August 2022
CASE STUDY 5
Hello, I am Saloni .S. Gangotri , a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.
CASE SHEET:
CHIEF COMPLAINTS:
c/o
- loose stools since 20 days
- generalised weakness
- blydypsia
- polyphagia
- backpain since 2 months
HISTORY OF PRESENT ILLNESS:
Patient was apparently normal but developed loose stools 20 days ago (4-6 episodes/day) and generalised weakness.
ASSOCIATED DISEASES:
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PAST HISTORY:
h/o
K/C/O DM since 3 years (stopped taking insulin)
K/C/O Polio.
No TB, Epilepsy.
PERSONAL HISTORY:
Regular Bowel movements.
Has normal micturition with no burning sensation with increased frequency.
Has no known allergies.
Regular alcohol drinker.
FAMILY HISTORY:
Has no history of Diabetes Mellitus, No HTN, No Cardiac Strokes, No cancers.
DRUG HISTORY:
GENERAL EXAMINATION:
-No palor
-No cyanosis
-No lymphadenopathy
-No icterus
-No edema of feet
-No clubbing of fingers
-Temp - normal
-GRBS - high
VITALS:
Temperature: Afebrile
Pulse: 90 beats per minute
Respiratory rate: 18 cycles per minute
Blood pressure: 120/80 mm of Hg
SPO²: 96
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 present
Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular? yes
Abdomen:
Shape : Scaphoid
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious and Alert
Speech: Normal
INVESTIGATIONS:
Biochemical investigations:
ECG:
GRAPHIC SHEET :
ULTRASOUND REPORT:
2D-ECHO REPORT:
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PROVISIONAL DIAGNOSIS
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