55 year old male with c/o 15 episodes of loose stools
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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
A 55 year old male farmer by occupation came to casualty with cheif complaints of loose stools since 2 days
Cheif complaints of 15 episodes of loose stools since 2 days .
Patient was apparently asymptomatic 2 days ago then he gives alleged h/o sunstroke 2 days ago,then he has h/o alcohol intake and outside food consumption on that day, following which he had 15 episodes of loose stools which are involuntary and watery in consistency, yellowish white
1 episode of vomiting,
low grade fever
No h/o sob,chest pain, palpitations
16/4/23
(He's not having any symptoms of
Pedal edema ,distension of abdomen ,chestpain
Patient
Tachepnic at time of presentation
Jvp raised
Apex 5thIcs @mcl
No crepts
No additional heart sounds or murmurs
Vitals - initially 70/40 at presentation
No response to fluids
Started on Noradrenaline @5ml/hr
Gradually tappered today morning
TropI -126 (yesterday)
Abg- met acidosis(hagma)
Today- No fresh complaints
Patient tachepnic +
Met acidosis ( resolved)
No complaints of chestpain
No Pedal edema)
Past history :-
N/k/c/o htn,dm,cad,tb,asthma
Personal history:-
Farmer by occupation
Diet -mixed
Appetite -narmal
Sleep - adequate
Bowel and bladder movements:- loose stools and since 2 days
Addictions:- drinks 90 ml alcohol 2-3 times a week since 20 years
General examination:-
Patient is conscious,coherent, cooperative
Pallor present, icterus,cyanosis, clubbing, generalized lymphadenopathy, bilateral pedal edema absent
Vitals:-
BP-60/40 mmhg
PR-63bpm
RR:- 45 cpm
Spo2:- 99% @RA
GRBS:- 157 gm/dl
Systemic examination:-
PA:
Inspection:
Round, large with no distention
Umbilicus: Inverted
No visible pulsation,peristalsis, dilated veins and localized swellings.
Palpation:
Soft, tenderness present in epigastric region
No signs of organomegally
Percussion:
No fluid thrill, shifting dullness absent
Auscultation:
Bowel sounds heard 2-3/ minute
CVS:
Inspection:
There are no chest wall abnormalities
The position of the trachea is central.
Apical impulse is not observed.
There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses.
Palpation:
Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line
Position of trachea was central
. Auscultation:
S1 and S2 were heard
There were no added sounds / murmurs.
RESPIRATORY SYSTEM:
Bilateral air entry is present
Normal vesicular breath sounds are heard.
CNS:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES :Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
CEREBELLAR FUNCTION
Normal function
No meningeal signs were elicited
Investigation;-
Provisional diagnosis:-
Hypovolemic shock 2° to ? dehydration 2° to GI losses ( gastro enteritis ) with acute kidney injury ? Pre renal ? Renal
With ? heart failure (Rt)
Treatment:-
1.IV fluids NS,RL @ 50-70 ml/hr
2.Inj NORADRENALINE (2 amp + 46 ml NS) @ 5ml/hr increase or decrease to maintain map > 65 mmhg
3.Inj monocef 1g/iv/bd (day 2)
4.Inj lasix 20 mg/iv/bd( if MAP >65MMHG)
5.Inj thiamine 200 mg in 100 ml NS over 30 minutes/iv/od
6. Ecosprin AV75/IO/po/hs
7. tab dolo 650 mg/po/sos( temp >100°F)
8.monitor vitals hourly
9.inform SOS
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