55yr old male came with involuntary loose stools since 2days

  Sahithi Nalabolu 

Roll no : 107

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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;- 

15/04/2023

            16/04/2023

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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