A patient of 57 years old female came with C/O loose stools since yesterday

 March 31/03/2023

 This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Name: Manvitha (intern)

A patient of 57 years old female came with C/O loose stools since yesterday 

And C/O vomitings since yesterday night (2:00)am

HOPI

Patient was apparently asymptomatic till yesterday morning and then developed loose stools, watery in consistency , yellowish in colour and foul smelling for which he went to local hospital and received IV gluids and antibiotics 

C/O vomiting, multiple episodes 10-12 episodes since yesterday and small in amount, watery

Vomiting associated with nausea and water 

Fever since 3 days high grade continuous chills present no cough sob and no burning micturition

Past history 

K/C/O DM since 10 years On tab glipizide (5mg) and tab Metformin 50mg

N/K/C/O HTN, Epilepsy, CAD, CVS

Personal history 

occupation house wife 

appetite normal 

diet non veg 

bowel and bladder movements loose stools 

no addictions 

family history insignificant


Menstural history 

age of menarche 13 years 

regular 5/30 day cycle 


General examination 

patient is conscious cooperative coherent well oriented to time place person 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema 











Vitals 

temperature : 98 F

PR: 95 

RR:16cpm 

BP 110/80mmhg 

spo2: 98 at room air 


Systemic examination 

CVS S1S2 heard no cardiac murmurs heard 

RS NAD NVBS heard 

P/A Soft and non tender scaphoid abdomen 

CNS : NAD 


Provisional diagnosis 

Acute gastroenteritis with K/C/O DM type 2


Investigations 









Chest X-ray 




 Treatment

IV fluids NS @ 15ml/hr

INJ PAN 40mg/IV/STAT

INJ ZOFER 4mg IV/STAT

INJ METROGYL 500mg IV TID

TAB SPOROLAC-DS PO/TID

INJ HAI 

INJ NEOMAL 1gm IV/STAT

TAB PCM 650ng PO/SOS


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