20-year-female with vomiting and loose stools

This is an online Blog book to discuss our patients deidentified health data shared after taking his/ her guardians to sign an informed consent

Here we discuss our patient problems through a series of inputs from the available Global online community of experts with n aim to solve those patient clinical problems with the current best evidence-based input
This Blog also reflects my patient-centred online learning portfolio.
Your valuable input on the comment box is welcome
I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competence in reading and comprehending clinical data including history, clinical findings, and investigations and coming up with a diagnosis and treatment plan.

CONSENT AND DEIDENTIFICATION : 

The patient and the attendees have been adequately informed about this documentation and the privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.


PRESENTING COMPLAINTS:
A 20-year-female



HOPI:
A 20-year-female nursing student came to casuality with 

ECG AT PRESENTATION:
INVESTIGATION CHART:

FEVER CHART:


USG ABDOMEN:
Was done on 20/12/2022, which showed evidence of:-
1. Liver : 13.8 cms with normal size and echotexture, no IHBRD.
2. Spleen: 10 cms with normal size and echotexture.
3. Right kidney 9.2 × 3.5 cms and Left kidney 10.1× 4.6 cms with normal size and echotexture, Corticomedullary differentiation maintained and normal PCS.
4. Uterus 7.5 × 3.5 cms; Fluid in pouch of Douglas.


TREATMENT:
1. IVF 1• NS @100ml/hr.
2. INJ. METROGYL 500mg/IV/TID.
3. INJ. CIPROFLOXACIN 200mg/IV/BD.
4. INJ. PAN 40 mg/ IV/OD.
5. INJ. ZOFER 4mg/ IV/OD.
6. TAB. ULTRACET /PO/BD.
7. MIX 1 ORS SACHET IN 1 LITER OF LUKEWARM WATER AND DRINK 200ml AFTER EACH EPISODE OF LOOSE STOOL.





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