68yr F with Vomitings and loose stools

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs 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 competency in reading and comprehending clinical data including history, clinical findings investigations and come up with diagnosis and treatment plan.


Case History-

A 68 YR old Female came with chief complaints of vomitings and loose stools since yesterday(19/06/2023) evening .


HOPI:

Patient was apparently asymptomatic till yesterday evening . She then had 6 to 9 episodes of vomitings from 6pm yesterday and 5-6 episodes of vomitings today(20/06/23) which are Non projectile , Non bilious , Non Blood tinged , Watery with food Particles as contents.

She also had loose stools since evening of 19/06/2023 about 7 to 8 episodes which were Watery, foul smelling and non blood stained.

H/O eating Fish yesterday evening .

Not Associated with Pain Abdomen, Fever 

No H/O- Chest Pain, Palpitations, SOB, Decreased urine output and Pedal Edema.


Past History- 

Not a K/C/O DM, HTN,TB,Epilepsy,CVA, CAD, Bronchial Asthma, Thyroid Disorders .

H/O Surgery done 10yrs back for Intestinal Perforation.


Personal History:

Diet- Mixed

Appetite- Decreased since 1 day

Bowel & Bladder Movements- Loose stools since 1 day &Regular urine output 

Sleep - Adequate

Addictions - None 


Family History - Not significant


GENERAL EXAMINATION-

Patient is Conscious, Coherent and Co operative .

No signs of Pallor ,Icterus Clubbing, Cyanosis, Lymphadenopathy and edema






Vitals-

TEMP: Afebrile 

BP: 100/70mmHg

PR: 104 bpm

RR- 26cpm

Spo2- 95% @RA

GRBS:147mg/dL


Systemic Examination:

CVS: Inspection

Chest wall is bilaterally symmetrical.

No precordial bulge is seen 


Palpation


JVP- Normal

Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 

Auscaltation-

S1&S2 are heard,no murmur found.


RESPIRATORY SYSTEM


Position of trachea- central

Bilateral air entry, normal vesicular breath sounds are heard.

No added sounds


CNS


Patient is conscious ,coherent and co operative , well oriented to time and space.

Speech normal.

No signs of meningeal irritation.

Motor and sensory system- Normal

Reflexes - present

Cranial nerves - intact




PER ABDOMEN


On inspection:

Abdominal distention - absent

On percussion::

Tympanic note - heard 


No shifting dullness

On auscaltation::

Bowel sounds heard 


Provisional Diagnosis-

AKI?( Renal) Acute Gastroenteritis? 




All quadrants are moving equally with respiration

Umbilicus - central and inverted

No scars,dilated veins, prominent Venous pulsations and visible peristalsis.


On palpation::

Superficial palpation- No Local rise in temperature and no tenderness

Deep palpation- No guarding, rigidity


INVESTIGATIONS 





RBS- 135mg/dl

Serology- Negative


CXR PA VIEW


ECG



Treatment-

1.IV Fluids - NS 

                   - RL

2.Inj.METROGYL - IV /TID

3.Inj.PAN 40mg IV/OD  

4.Inj.ZOFER 4mg IV/BD

5.Tab.SPOROLAC Po/TID

6.Tab.DOLO 650mg PO/SOS

7.ORS in 1L water 

8.Monitor Vitals 4th hrly



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