This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability.
A 60 year old female who is a resident of Narsimpeta and an agricultural labourer was brought to the casualty with chief complaints of multiple episodes of loose stools and vomiting with fever for the past 10 days.
History of presenting illness
May,2022: The patient experienced a significant loss in weight that was noticed by herself and her daughter that started sometime during the month of May. She complains of a change in the size of her clothes and says that they are all now loose.
May 2nd,2022: Starting this day and for the next 22 days, the patient consumed 1 bottle of Toddy each day that she shared with her granddaughter. She diluted the toddy with water before consumption.
June 1st ,2022: She reports feeling extremely gassy owing to which she stopped drinking toddy. She complained of abdominal pain that rose till her chest and was relieved by burping.
June 3rd,2022: The patient had 10 episodes of watery diarrhea that was assosciated with abdominal pain. This went on for 4 days. She also had a fever,as reported by her daughter.
June 7th-June 11th,2022: Her symptoms were relieved with no treatment. The symptom free interval lasted for 5 days.
June 12th,2022: The patient once again had 4 episodes of watery diarrhea during the day. This was followed by 2 episodes of vomiting at night. The vomit was not bilious and non projectile in nature. The diarrhea was not bloody. She was taken to the hospital by her daughter where she is currently admitted.
June 13th,2022: As of this day, the patient reports having 5 episodes of watery diarrhea. The diarrhea is preceeded by a migrating abdominal pain which is relieved after passing stools. The pain is worsened by consumption of even small quantities of food or water.
No H/o blood in stools or vomitus, hematuria, burning micturition
No H/o deviation from regular diet or intake of non homemade food in the past 15 days.
No H/o foul smelling vaginal discharge/itching, itching of skin or nails, cough.
The patient traces her finger over her abdomen to show the typical movement of her pain. The pain starts with the onset of meals and ultimately migrates below the umbilicus, ending in a sudden urge to defecate. The pain is relieved by passage of stools, although she feels tenesmus.
Past history:
- She is not a known case of Diabetes, Hypertension, Asthma, CAD, hypothyroidism, TB, RA.
- No drug history.
- No history of other recent illnesses.
Daily routine:
The patient lives with her 7 year old granddaughter. She wakes up at 4am everyday, finishes her household chores and leaves to work at 8am. She has lunch at 2pm. She comes back home at 4pm.
Personal History
Diet: Mixed
Appetite: Decreased due to pain
Sleep: adequate
Bowel and Bladder movements: Increased frequency of bowel movements, small quantities of stool.
No known allergies
Consumes Toddy in the summers
Menstrual history: She attained menopause 15 years ago.
Family History
No history of similar illnesses among immediate family members.
The patient is married and has one daughter (27yrs). Her husband died 25 years ago and she lost her son 10 years ago, both due to accidents.
No history of DM,HTN,CVA, TB, Asthma or CAD among her immediate family members.
General examination
The patient is conscious, coherent, co-operative; well oriented to time, place and person.
Moderately built, well nourished.
No pallor, icterus,cyanosis, clubbing, lymphadenopathy, edema.
Vitals
HR: 114 bpm
BP: 130/100 mmHg
RR: 20cpm
TEMP: 98.8
SpO2 at RA: 98%
GRBS: 98 mg%
Systemic Examination
RS: BAE+, NVBS
- Chest is symmetrical
- Trachea is central
- Chest expansion is symmetrical b/l
CVS: S1, S2 heard; no murmurs
P/A: soft, non tender at the time of the examination, no organomegaly or ascites
CNS: Higher mental function : intact
Cranial nerve functions : normal and intact
Motor system:
•Muscle Bulk: Normal on inspection and palpation on all 4 limbs, uniform and symmetrical on right and left sides
Muscle tone: Normal in both upper and lower limbs on both the right and left sides
•Muscle power: Symmetrical on right and left sides, normal
•Reflexes: Both superficial and deep reflexes present and normal
Sensory system: Normal
Investigations:
HIV 1/2 RAPID TEST: REACTIVE
STOOL FOR OCCULT BLOOD: POSITIVE
SERUM ELECTROLYTES: HYPOKALEMIA
SERUM CREATININE: ELEVATED
LFT: ELEVATED AST, ALT, ALP
HEMOGRAM: 12/6/22
BLOOD UREA
RANDOM BLOOD SUGAR
BLOOD GROUPING AND TYPING: O+
Provisional diagnosis: 60 year old female with HIV and gastroenteritis currently undergoing treatment.
Treatment:
- IV FLUIDS: 1 UNIT NS AND 1 UNIT RL AT 75ml/hr
- INJ CIPROFLOXACIN 500MG IV/ BD
- INJ ONDANSETRON 4MG IV/BD
- INJ PANTOPRAZOLE 40MG IV/OD
- CAP RACECADOTRIL 100MG PO BD
- INJ OPTINEURON( B COMPLEX) 1 AMP IN 100ML NS OD
- INJ METRONIDAZOLE 400MG IV/BD
- TAB SPOROLAC (PROBIOTIC)*2 PO TID
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