General medicine posting case 4

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 diagnosis and treatment plan

Ch.preethi

Admission number:176050
85 year old men came to causality on 31/01/23 with 

CHEIF COMPLAINTS:
A 85 YEAR OLD MALE PATIENT CAME TO CASUALTY WITH CHEIF COMPLAINTS OF
C/O LOOSE STOOLS SINCE 3-4 DAYS AND VOMITINGS SINCE 3-4 DAYS.

HOPI:
PATIENT WAS APPARENTLY NORMAL 3-4 DAYS BACK.THEN HE HAD 4-5 EPISODES OF WATERY BLACK COLOURED STOOLS SINCE THEN AND HAD LOOSE STOOLS FOR LAST 4 DAYS.STOOLS WERE FOUL SMELLING, ASSOCIATED WITH PAIN ABDOMEN .
H/0 VOMITINGS SINCE 3-4 DAYS,3 EPISODES PER DAY.NON PROJECTILE,NON BILIOUS,NON FOUL SMELLING WITH FOOD PARTICALS AS CONTENTS.
H/O PAIN ABDOMEN - SQUEEZING TYPE AROUND UMBILICUS AND RADIATING TO BOTH LUMBAR REGIONS.
H/O LOSS OF APPETITE SINCE 1 WEEK 
H/O DECREASE URINE OUTPUT.
H/O SHORTNESS OF BREATH AT REST-NON PROGRESSIVE.
NO H/O FEVER/BURNING MICTURITION.

HISTORY OF PAST ILLNESS:
NOT A K/C/O DM/HTN/TB/EPILESPY/ CVA/CAD/THYROID DISORDERS.
H/O TRAUMA 30 DAYS BACK -WHILE WALKING DOWN STREET HE FELL DOWN ON ROAD CAUSING INJURY TO THROAT DUE TO A STICK SINCE THEN HE IS NOT EATING WELL.

PERSONAL HISTORY:
DIET - MIXED
SLEEP- ADEQUATE
BOWEL -IRREGULAR
BLADDER- DECREASE IN URINE OUTPUT SINCE 4DAYS.
APPETITE- LOSS OF APPETITE SINCE 4 DAYS
HABITS-SMOKING(CHUTTA) FOR 30 YEARS NOT SMOKING NOW .

FAMILY HISTORY:
NOT SIGNIFICANT FAMILY HISTORY.

GENERAL PHYSICAL EXAMINATION:
PATIENT IS CONSCIOUS COHERENT COOPERATIVE .
NO  PALLOR, CYNOSIS,ICTERUS,CLUBBING,
LYMPHADENOPATHY.
VITALS:
TEMP-98.5F
PR-110/MIN
RR-20/MIN
BP-70/50MMHG
SPO2-98% AT ROOM AIR
GRBS-164 MG%.

SYSTEMIC EXAMINATION:
P/A- SOFT DIFFUSE TENDERNESS ALL OVER ABDOMEN.VOLUNTARY GUARDING.
CVS-S1 S2 PRESENT,NO MURMURS
CNS-NAD
GRBS-92MG/DL

DIAGNOSIS:
ACUTE GASTROENTERITIS DYSELECTROLYTEMIA
DYSPHAGIA UNDER EVALUATION

INVESTIGATIONS:
ON 31/01/23
BT-B POSITIVE
ESR-45
HB-8.8
TLC-11000
RBC-2.94
PLT-2.32
RBC-1.43
TB-0.65
DB-0.18
SGOT-28
SGPT-13
ALP-124
TP-4.2
ALBUMIN-2.1
A/G RATIO-1.01
BLOOD UREA-59
S.CREATININE-1.2
NA-115
K-3.0
CL-80
I CA-0.94
HBA1C-6.7
S.IRON-42.
         
ECG ON 31/01/23
USG ON 31/01/23
IMPRESSION:
BILATERAL GRADE 1 RPD CHANGES
LEFT HYDROURETERONEPHROSIS.

TREATMENT:
1.IV FLUIDS  2 POINT NS-BOLUS GIVEN 
2.IV FLUIDS 1 POINT NS@100ML/HR
2.INJ.CIPROFLOXACIN 500MG IV/BD
3.INJ PAN 40MG IV/OD
4.INJ ZOFER 4MG IV/TID
6.TAB SPOROLAC-DS PO/TID
7.1 ORS SACHET IN 1 LITRE OF WATER 200ML AFTER EACH LOOSE STOOL EPISODE
8.GRBS MONITORING 6TH HOURLY
8AM-2PM-8PM-2AM
9.STRICT I/O CHARTING.

ON 01/02/23

 

S
PATIENT C/0 VOMITINGS 4 EPISODES
LOOSE STOOLS BLACK COLOURED WATERY 4-5 EPISODES
DIFFICULTY IN SWALLOING.



O
PATIENT IS CONSCIOUS COHERENT COOPERATIVE .
NO  PALLOR, CYNOSIS,ICTERUS,CLUBBING,
LYMPHADENOPATHY.

VITALS:
TEMP-98.5F
PR-82/MIN
RR-20/MIN
BP-100/60MMHG
SPO2-98% AT ROOM AIR
GRBS-92 MG%.

SYSTEMIC EXAMINATION:
P/A- SOFT DIFFUSE TENDERNESS ALL OVER ABDOMEN.VOLUNTARY GUARDING.
CVS-S1 S2 PRESENT,NO MURMURS
CNS-NAD
GRBS-92MG/DL

INVESTIGATIONS:
S.ELECTROLYTES:@1PM
NA-120
K-2.9
CL-96
ICA-0.96
PT-17
APTT-34
INR-1.25
CA-9.6
P-2.0
MG-1.8
SPOT URINE PROTIEN-10.9
SPOT URINE CREATINE-23.5
SPOT URINE A/G RATIO-0.46
 
X RAY ON 01/02/23

DIAGNOSIS:
ACUTE GASTROENTERITIS DYSELECTROLYTEMIA
DYSPHAGIA UNDER EVALUATION

TREATMENT:
1.INJ.KCL 2AMP IN 500 ML NS /STAT
1.IV FLUIDS NS@75ML/HR
2.INJ.CIPROFLOXACIN 200MG IV/BD
3.INJ PAN 40MG IV/OD
4.INJ ZOFER 4MG IV/TID
5.INJ BUSCOPAN 10 AMP IV/STAT
6.TAB SPOROLAC-DS PO/TID
7.1 ORS SACHET IN 1 LITRE OF WATER 200ML AFTER EACH LOOSE STOOL EPISODE
8.GRBS MONITORING 6TH HOURLY
8AM-2PM-8PM-2AM
9.STRICT I/O CHARTING.

Date : 02/02/23


S
PATIENT C/0 3 EPISODES OF LOOSE STOOLS 10PM
3AM
7AM
NO VOMITING EPISODES 
NO FEVER SPIKES



O
PATIENT IS CONSCIOUS COHERENT COOPERATIVE .
NO  PALLOR, CYNOSIS,ICTERUS,CLUBBING,
LYMPHADENOPATHY.

VITALS:
TEMP-97.1F
PR-82/MIN
RR-20/MIN
BP-120/70MMHG
SPO2-98% AT ROOM AIR
GRBS-101MG%.

SYSTEMIC EXAMINATION:
P/A- SOFT DIFFUSE TENDERNESS ALL OVER ABDOMEN.VOLUNTARY GUARDING.
CVS-S1 S2 PRESENT,NO MURMURS
RS-B/L AIR ENTRY PRESENT,NVBS HEARD
CNS-NAD

A:
ACUTE GASTROENTERITIS DYSELECTROLYTEMIA
DYSPHAGIA UNDER EVALUATION ?H/O TRAUMA

INVESTIGATIONS:

P:
1.IV FLUIDS NS@75ML/HR
2.INJ.CIPROFLOXACIN 200MG IV/BD
  8AM-8PM
3.INJ PAN 40MG IV/OD
   8AM
4.INJ ZOFER 4MG IV/TID
  8AM-2PM-PM
5.INJ BUSCOPAN 10 AMP IV/STAT
6.INJ KCL 2AMP IN 500ML NS SLOWLY OVER 5HOURS
7.TAB SPOROLAC-DS PO/TID
8.1 ORS SACHET IN 1 LITRE OF WATER 200ML AFTER EACH LOOSE STOOL EPISODE
8.GRBS MONITORING 6TH HOURLY
8AM-2PM-8PM-2AM
9.STRICT I/O CHARTING.
10.VITALS MONITORING 2ND HRLY.


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