History of the disease

I General Biographical Particulars

Full Name: x
Age: 18
Marital Status: Single
Profession: Student
Clinical diagnosis: unknown yet
II Patients complaints at the onset of the disease
On 22 March 2016, patient suffered from vomiting, diarrhea, abdominal
discomfort for several times.
III History of Presenting illness
On 22 March 2016, patients vomited and had diarrhea for several times.
Patient also had high temperature. This situation continues until patients call
ambulance to hospital on 24 of March. On the day of admission, patient has
high temperature (39-40 degree Celcius), vomit and diarrhea several times
per day. Patient also feel headache, weakness, joint pain, thirsty during
hospitalization.
Patient felts thirsty at the beginning of hospitalized but currently this
condition gets better.
IV Epidemiological History
Patient claimed that he met a friend who travelled to Kazashtan and had
similar symptoms like vomit, diarrhea in January.
V Life History
Past Medical History: Nil
Harmful Habits: smoking for one and half years
Occupational Hazards: Nil
Social history (housing condition: Unknown
Allergy for nuts
VI General Examination
Patient are sleepy , tired and lying on the bed during conversation .
Skin : pale, dry
Mucous membranes: dry
Lymphatic system : No examined
Respiratory : lungs are clear, Respiratory rate : 20 ( normal), Ascultatiuon :
normal
Cardiovascular system : dual rhythm no murmur, AP : unknown, pulse :
80/min
Digestive system: dry white tongue,
Superficial Palpation

Deep Palpation
Size of liver
Spleen size:
Stool : watery
Urogenital System :
Kidneys
Decreased urination
Urine : clear yellow color
Nervous System: Conscious but feel sleepy
VII Provisional (suggested) diagnosis and substantiation of diagnosis
Food poisoning, Gastroenteritis variant, moderate severity
VIII Differential Diagnosis
Cholera
Salmonellosis
IX Plan of investigation
1. Complete Blood Count
2. Biochemical Analysis
3. Serological tests O-diagnostics for Staphylococcal, Bacilius , Clostridium
,Salmonellosis, Cholera
4. Bacteriological Examination (culture from stool , vomitus, blood, urine)
X Clinical (final) diagnosis and Substantial of Diagnosis
XI Treatment
XII Epicrisis
XIII Prognosis