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


Comments

Post a Comment

Popular posts from this blog

20 yrs female with abdominal pain and vomiting

Image
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 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: Lakshmi Manvitha Yechuri Roll no: 169  I've 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 a diagnosis and treatment plan. CASE PRESENTATION : A 20 yr old female, student by occupation has come to the OPD on 22nd march 2022 with the chief complaints of Abdomi...
Read more

A 45 year old female came with C/O pain in left hip since 4 months

Image
  Feb 22, 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 45 years old female came with C/O left hip pain since 4 months  HOPI Patient was apparently asymptomatic 3 years back then she had an alleged history of fall in rain and injured her left hip. The pain subsided on its own During past 4 months she is complaining of dragging type of pain radiating to left hip to left ankle not associated with any tingling sensation. Swelling present 4 months back which subsided on its own...
Read more

21 years old female patient with fever and headache since 3 days

Image
Feb 19/02/2023   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 21 year old female patient came to causality with chief complaints of  fever since 3 days  headache since 3 days and  body pains since 3 days  HOPI  Patient was apparently asymptomatic 3 days back then she developed fever of high grade continuous with chills and rigor and headache (diffuse) and  body pain relieving on medication but recurring no diurnal variation cold negative no cough no vomitings ...
Read more