62 YEAR OLD FEMALE WITH LOOSE STOOLS AND VOMITINGS.

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This Elog also reflects my patient centered online learning portfolio.

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 a diagnosis and treatment plan.

62 year old female farmer by occupation came with chief complaints of 

-Loose stools since 2 days

-Vomitings 2 days ago

History of present illness:

-Patient was apparently asymptomatic 2 months ago when she had a history of fall from her bed then developed pain in her right shoulder .she then approached local doctor for which she was given pain killers but not relieved. She then went to the private hospital and was treated symptomatically by medication. 

-2 days ago patient experienced Vomitings 3 to 4 episodes Non projectile, non bilious ,non blood tinged food as Content.

On the same day she had  5 to 6 episodes of loose stools yellow colored, watery non foul-smelling they went to RMP doctor  and was treated Vomitings got subsided. 

-She then went for government hospital where they started on symptomatic treatment and fluids but was not relieved.

-Since today morning she had 10 episodes of
loose stools  

-No history of fever,abdominal pain,intake of outside food.

Daily routine:

She is a farmer by occupation used to work in paddy fields but after her history of fall she stopped working.

She wakes up around 5 am early in the morning

Does some household works then drinks tea at 7 am .she cooks food for her family then takes her breakfast at around 10 pm.She takes her afternoon lunch at around 2 pm sleeps for sometime and then helps in household works and completes her dinner by 9 pm goes to bed by 10 pm.

Since 2 days her daily routine got disturbed and she was mostly on liquid diet since 2 days.

Past history:

Not a k/c/o Hypertension ,DM, TB,Bronchial Asthma, Epilepsy, CVA and thyroid disorders. 

PHYSICAL EXAMINATION:

Patient is conscious coherent and cooperative 

Moderately built and moderately nourished 

 Well oriented to time place and person

VITALS 

TEMPERATURE:Afebrile 

Pulse rate: 89bpm

BP: 130/90 mmhg

No Pallor 

No icterus 

No cyanosis 

No clubbing 

No lymphadenopathy

SYSTEMIC EXAMINATION:

ABDOMEN EXAMINATION:

Shape of abdomen: Distended 

 No tenderness 

No palpable mass

Dull on Percussion 

  

CNS EXAMINATION 

No focal neurological deficit 

CVS EXAMINATION:

Cardiac sounds S1 S2 heard

No murmers heard.

RESPIRATORY SYSTEM 

Bilateral air entry present 

Normal vesicular breath sounds heard

Trachea: central

Clinical images:

 

 

RBS:

RFT:

 

LFT

Hcv:

Hemogram:

Cue:

Hiv:

HBSAG:

Provisional diagnosis:

Acute gastroenteritis 

TREATMENT:

1.Inj Metrogyl 500 ng iv/Tid

2.Iv fluids NS @75 ml per hour

3.Inj Pan 40mg iv/od

4.Tab sporolac Ds po /TID

5.Tab Redotil 100 mg Po/BD

4.2 ORS in 1 liter of water 200 ml after every episode