A 52 year old with vomitings and loose stools

 This is an online E log book to discuss our patient's de-identified health data shared after taking his signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

 HEMA SUMANASRI KANDREGULA 

 ROLL NO 67

 I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Case :

A 52 yr old male came to the casualty with chief complaints of 

  • vomitings since yesterday
  • loose stools since yesterday .

History of present illness : 

  • Patient was apparently asymptomatic until yesterday mrng .
  • He complaints of vomitings 6-8 times which were non projectile, non bilious and food or water as content since yesterday mrng.
  • He also complaints of loose stools 6-8 times, which was watery, no blood in stools, tenesmus -ve.
  • No complaints of pain abdomen, fever , burning micturition.

History of Past illness :

  • No history of similar complaints in the past.
  • Not a k/c/o DM, HTN, TB , Asthma , Epilepsy, CAD.

Family history - not significant

Personal history - 

  • Diet - mixed 
  • Appetite - increased 
  • Bowel & bladder movements- regular , decreased urine output since yesterday 
  • Addictions - occasional alcohol consumer.

GENERAL EXAMINATION 
The patient was examined in a well lit room after taking consent.

  •  Patient is conscious, coherent and cooperative and is well oriented to time, place and person.
  • No pallor , icterus , cyanosis , clubbing lymphadenopathy , edema .

VITALS 

  • Temp - Afebrile 
  • BP- 90/60 mmHg
  • PR- 70 bpm 
  • RR -19cpm 
  • SpO2 -99% @RA

Systemic examination 

  • CVS - S1 S2 +ve , No murmurs 
  • RS - NVBS +ve , BAE +ve 
  • P/A - soft , non tender , BS +ve 
  • CNS - NAD 
Investigations :







PROVISIONAL DIAGNOSIS 

Acute gastroenteritis.

Plan of action :

  • Infusion NS @ 150ml/hr
  • Inj. Pantop 40mg IV/OD
  • Inj. Zofer 4mg IV/TID
  • Inj. Metrogyl 400ml IV/TID
  • Inj. Nedmol 1gm IV sos if temp >101c
  • Tab. Sporlac PO/TID
  • Tab. Radotil 100mg DO/TID
  • Monitor BP and temperature
  • Inj. Ciprofloxacin.


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