31 year old male with 20 episodes of loose stools

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. 

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 and investigations. 

——————————————————

A 31 year old male, farmer by occupation, came to general medicine OPD with chief complaints of: 
• loose stools since two days (20 episodes)

HOPI:-
•The patient was apparently asymptomatic two days back, then he developed episodes of loose stools after consuming outside food. He consumed fried rice the night before commencement of loose stools. 

•He had 28 episodes of loose stools on the first day and 20 episodes on the second day. The stools were of large quantity, non foul smelling and loose. 
It was associated with abdominal pain 

•He has fever since 1 day, which is high grade and intermittent. 
It’s not associated with cold, cough, SOB, sore throat 

•The patient also complains of burning micturition since one day. 
Not associated with hematuria, pyuria, decreased urine output. 
No complains of chest pain, palpitations. 

Past History :-
Not a known case of diabetes, hypertension, CVA, CAD, TB, epilepsy, thyroid disorders.

Treatment History 
Not significant 

Personal History
•Diet: Mixed 
•Appetite: Normal 

Normally, his daily schedule looks like;
He takes his breakfast at 8 am, followed by lunch at 1pm (which he sometimes skips and opts for an early dinner)
He eats dinner at 8pm usually 

•Bowel and bladder: 20 times a day from one day
                                Normal 
•Addictions: Occasional alcohol intake (one beer)
                    Smoked occasionally two years back
Allergies: none 

Family History: 
Not significant 

-> GENERAL EXAMINATION: 

Patient is examined in a well lit room after taking informed consent. 
Patient is conscious, coherent and cooperative
No signs of pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, pedal edema. 

•Vitals
(At time of admission) 
Temp:101F
Pulse:64bpm
RR:16cpm
Bp:120/70 mm of gg
Spo2:96%

-> SYSTEMIC EXAMINATION: 

Abdominal Examination 





Inspection; 
Shape: Truncal obesity is seen 
Flanks are full 
Umbilicus is central and everted 
Skin over abdomen is normal 
No visible pulsations, sinuses or engorged veins. 

Palpation ; 
No tenderness or local rise of temperature in all 9 quadrants .
Organ palpation: No organomegaly 
                            Spleen, gall bladder not palpable 

Auscultation; 
Bowel sounds are heard 


                          INVESTIGATIONS 



USG
Borderline splenomegaly 


Fever chart 

At admission 




On 9/6/23




On 11/6/23

Hemogram:- 

Haemoglobin:14.5gm/dl
Total count:5,300cells/cumm
Neutrophils:79
Lymphocytes: 11
Eosinophils:01
Monocytes:09
Basophils:00
PCV:42.4
MCV:88.3
MCH:30.2
RDW CV:11.9
RDW SD:38.9
RBC count:4.80
Platelet count:1.51lakh/cumm

Urine examination 

Colour:Pale yellow
Appearance:Clear
Reaction:Acidic
SP.gravity:1.010
Albumin:+
Sugar:Nil
Bile salts:Nil
Bile pigments: Nil
Pus cells:3-6
Epithelial cells:2-4
Red blood cells:Nil

Blood urea:26
Serum creatinine: 1.0

Hbs Ag RAPID:Negative

HIV 1/2 Rapid test:non
Reactive

LFT

Direct bilirubin:0.24gm/dl
Total bilirubin:0.86gm/dl
AST:27 IU/L
ALT:40 IU/L
Alkaline phosphatase:113 IU/L
Total protein: 6.4 gm/dl
Albumin:4.08 gm/dl
A/G Ratio:1.76

Serum Electrolytes 

Sodium-141mEQ/L
Potassium -3.8 mEQ/L
Chloride-106 mEQ/L
Calcium-1.16 mmol/L


Provisional Diagnosis:- 
Gastroenteritis 

Treatment:- 

1) IV FLUIDS 2NS @75ML/HR
2) INJ.PCM 1GM IV/SOS
IF TEMP >101F
3) INJ OPTINEURON IN 100ML NS IV/OD
4) TAB.SPOROLAC PO/OD
5) TAB.PAN 40MG PO/OD
6) TAB.DOLO 650MG PO/sos
7) TAB. ZOFER 4MG PO/SOS
8) PLENTY OF ORAL FLUIDS 
9) MONITOR BP,PR,RR,TEMP EVERY 4TH HOURLY

Comments

Post a Comment

Popular posts from this blog

PRE FINAL OSCE

  1) Criteria for weaning patient off of ventilator?   -> Subjective assessment:      Adequate cough      No neuromuscular blocking agents       Absence of excessive trachea bronchial secretions       Reversal of underlying cause of respiratory failure         -> Objective assessment:      Stable cardiovascular status      Heart rate <140 beats/min      No active myocardial ischemia       Adequate heamoglobin level >8g/dL      Systolic blood pressure 90-160mmHg       -> Adequate oxygenation:       Tidal volume >5mL/kg       Vital capacity >10mL/kg       Proper Inspiratory effort        Respiratory rate <35/min       PaO2 >60mmHg, PCO2 <60mmHg       No significant respiratory acidosis  • Reference- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/ 2) CPAP for pneumonia treatment  • The Cpap does not treat pneumonia directly but can reduce the work of breathing often seen with pneumonia. In most cases rpneumonia is unilateral and can interfere with gas e
Read more

83 year old male with shortness of breath

Image
This is an a 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. ——————————————————— ————— - > Chief complaints: • Cough since 16 days • Fever since 14 days • Shortness of breath since 12 days -> History of Presenting illness: Patient was admitted to ICU on 20/11/23
Read more

General Medicine Assignment

Monthly Online Summative Assessment  July 03, 2021 Tejomayi Algubelli  Roll no: 130 General Medicine assignment  Question 1  1. Pulmonology  Review:  https://divyaraju266.blogspot.com/2021/05/answers.html Case:  https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html A 55-year-old female with chief complaints of shortness of breath, pedal oedema and face puffiness.   This is a case of acute exacerbation of COPD associated with right heart failure and bronchiectasis. After investigations were done, she was diagnosed with right heart failure ; because of low oxygen levels due to COPD. This also leads to renal failure causing the pedal edema and facial puffiness. Shortness of breath seems to be caused by bronchiectasis which is the thickening of bronchi. Required medication was given to alleviate the symptoms such as antibiotics, diuretics and steroids.  2. Neurology  Review:  https://divyaraju266.blogspot.com/2021/05/answers.html Case:  https://ris
Read more