59 yr male came with loose stool

 I am Soumya 5th semester student .


This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

CASE SCENARIO

59 yr man from manuguru ,a roadside textile vender came to casualty with cheif complaints of

Loose stools since 1 day 

Fever with chills and rigor 

5 episode of vomitings since 1 day


HISTORY OF PRESENT ILLNESS

Patient was apparently normal 1 day ago

Since the previous night of admission he had several episodes of loose stools - yellow coloured,large volume watery,not blood stained,non foul smelling and could not sleep thorough out the night.   

Also then developed a high grade fever with chills and rigor 

The next day he also several episodes of loose stools (more than 20 episodes throughout the day) and also had about 5 episodes of vomitings 

Then he went to local hospital and had fluid infusion then came to our hospital 

Past History of similar complaints: He had same complaints about 3 years back

HISTORY OF PAST ILLNESS

3 years ago he had back pain and lower limb pain for which he got some Othropedic treatment in our hospital - the got relieved on medication,

he also diagnosed DM during the same visit ,took Metformin for 3 months and advised to maintain a strict diet.

Not known case of HTN, epilepsy,asthma ,CAD

PERSONAL HISTORY:

Married

Occupation: textile vender 

Diet: Mixed 

Appetite: Normal

Bowels: 

Micturation: normal 

Known Allergies: No

Addictions :No

FAMILY HISTORY:

No significant family history 

General Examination. 

No Pallor,icterus , cyanosis, clubbing , lymphadenopathy, pedal edema 

VITALS:

Temperature - 101.1 F

BP:-100/70mmHg ,

PR:- 117bpm,

RR- 21 cpm, 

Spo2:-96%

GRBS:136mg/dl

Systemic examination:

CARDIOVASCULAR SYSTEM

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No


RESPIRATORY SYSTEM

Dyspnoea:No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Adventitious sounds : No

ABDOMEN

Shape - Scaphoid

No tenderness, palpable mass, No Fluid

No bruits 

Liver not palpable

Spleen not palpable

Bowel sounds No

CNS Examination

Conscious coherent cooperative

Speech normal

No signs of meningitis

Cranial nerves, motor system, sensory system Normal. 

INVESTIGATIONS :

2/9/22-















3/9/22 -





4/9/22-




PROVISIONAL DIAGNOSIS :

Acute gastroentiritis


TREATMENT :

Pt - c/c/c

Temp 101.1 F

PR - 112 bpm

BP - 100/70 mmHg

RS - BAE+, NVBS

CVS - S1 & S2 are heard    

P/A soft

1.INJ.NEOMOL 1 gm IV/SOS

2.T.SPORLAC DS PO/QID

3.T.PAN 40 mg PO/OD

4.T.ZOFER 4 mg PO / SOS

5.IV FLUIDS NS @50 ml/hr continuous Iv

6.GRBS Monitoring 6 th hourly

7. BP ,PR Monitoring 12 th hourly

8.T. DOLO 650 mg PO/TID

9.Temp monitoring 4 th hourly

10.Inj. METROGYL 400 mg IV /BD


3/9

Pt - c/c/c

Temp 97.6 F

PR - 89 bpm

RR 22 cpm

BP - 110/70 mmHg

RS - BAE+, NVBS

CVS - S1 & S2 are heard    

P/A soft

1.Inj. METROGYL 500 mg IV /TID

2.IV FLUIDS NS @50 ml/hr continuous Iv

3 T. DOLO 650 mg PO/TID

4.T.SPORLAC DS PO/QID

5T.PAN 40 mg PO/OD

6.T.ZOFER 4 mg PO / SOS

7.GRBS Monitoring 6 th hourly

8. BP ,PR Monitoring 12 th hourly

9.Temp monitoring 4 th hourly

10.INJ.NEOMOL 1 gm IV/SOS

11. Inj. CIPROFLOXACIN 500 mg /IV /BD

4/9 

Added 12. T.SEPTRAN DS PO/OD


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