31 year old male with loose motions since 1 day
A 31 Year old male presented to the casualty with complains of 20 loose stools since 1 day.
Patient was apparently asymptomatic till yesterday night then consumed outside food(fried rice) after which he developed loose stools of 20-25 episodes per day with abdominal pain.
Stools were of large quantity, loose in consistency and non-foul smelling.
He also has Fever since 1 day, Not associated with chills and rigors
Fever is of High grade, intermittent and not associated with cough, cold, SOB, sore throat.
The patient also complains of burning micturition since 1 day
No C/O chest pain, palpitations, constipation, decreased urine output, hematuria, pyuria.
DAILY ROUTINE:
Patient is a 31 year old male. He is married and has 3 kids. He is a farmer by occupation. He wakes up at 6am everyday and freshens up and goes to his farm. He comes back home at 8am and has breakfast and returns to farm. He sometimes has his lunch at 1:00pm and the other times he skips it and has a early dinner. He comes back home at 7:00pm and spends time with his family. He eats dinner at 8pm and sleeps at 11:00pm.
PAST HISTORY
- Not a known case of DM, HYPERTENSION, TUBERCULOSIS, CVA, CAD, THYROID DISORDERS, BRONCHIAL ASTHMA.
PERSONAL HISTORY
Diet: mixed
Sleep: adequate
Bowel: 20 stools/day since yesterday
Addictions: the patient drinks 1 beer during functions
Allergies: nil
Family history: not significant
GENERAL EXAMINATION
Patient is examined in a well lit room after taking an informed consent.
he is conscious, coherent and cooperative;
No signs of pallor, icterus, clubbing, cyanosis, generalized lymphadenopathy, pedal edema
VITAL AT THE TIME OF ADMISSION: (08/07/23)
Temp:101F
Pulse:64bpm
RR:16cpm
Bp:120/70 mm of hg
Spo2: 96%
Systemic examination:
ABDOMINAL EXAMINATION:
On inspection:
-Truncal obesity is seen.
Umbilicus is central and inverted.
-There are no visible pulsations, peristalsis, sinuses or engorged veins.
PALPATION:
-There is no local raise of temperature
-No organomegaly.
AUSCULTATION:
Bowel sounds are heard.
RESPIRATORY SYSTEM EXAMINATION
-Bilateral air entry is present, normal vesicular breath sounds heard.
CNS EXAMINATION:
No functional deficits
CARDIO VASCULAR SYSTEM
S1 and S2 are heard. No murmurs are heard
INVESTIGATIONS:
08/07/23
HEMOGRAM
Haemoglobin:14.5gm/dl
Total count:5,300cells/cumm
Neutrophils:79
Lymphocytes: 11
Eosinophils:01
Monocytes:09
Basophils:00
PCV:42.4
MCV:88.3
MCH:30.2
RDW CV:11.9
RDW SD:38.9
RBC count:4.80
Platelet count:1.51lakh/cumm
COMPLETE URINE EXAMINATION
Colour:Pale yellow
Appearance:Clear
Reaction:Acidic
SP.gravity:1.010
Albumin:+
Sugar:Nil
Bile salts:Nil
Bile pigments: Nil
Pus cells:3-6
Epithelial cells:2-4
Red blood cells:Nil
Casts:Nil
Crystals:Nil
Amorphous deposits:Absent
Others:Nil
Blood urea:26
Serum creatinine: 1.0
Hbs Ag RAPID:Negative
HIV 1/2 Rapid test:non
Reactive
LIVER FUNCTION TEST
Direct bilirubin:0.24gm/dl
Total bilirubin:0.86gm/dl
AST:27 IU/L
ALT:40 IU/L
Alkaline phosphatase:113 IU/L
Total protein: 6.4 gm/dl
Albumin:4.08 gm/dl
A/G Ratio:1.76
SERUM ELECTROLYTES
Sodium-141mEQ/L
Potassium -3.8 mEQ/L
Chloride-106 mEQ/L
Calcium-1.16 mmol/L
USG Abdomen: Borderline splenomegaly
09/7/23
RENAL FUNCTION TEST
Urea-20mg/dl
Creatinine-1.1mg/dl
Uric acid-4.6mg/dl
Calcium-9.8
Phosphorus -2.9
Sodium-138
Potassium -3.6
Chloride -102mEq/l
Hemogram
Haemoglobin: 13.7gm/dl
Total count: 4,200cells/cumm
Neutrophils:73
Lymphocytes: 17
Eosinophils-01
Monocytes:09
Basophils:00
PCV:40
MCV:88.3
MCH:30.2
MCHC:34.3
RDW-CV:11.9
RDW-SD:39.2
RBC-4.53 million/cumm
Platelet count -1.5 lakh/cumm
11/07/23
Hemogram
Haemoglobin: 15.0gm/dl
Total count :4,000cells/cumm
Neutrophils:40
Lymphocytes: 48
Eosinophils:02
Monocytes:02
Basophils:00
PCV:42.6
MCV:86.6
MCH:30.5
MCHC:35.2
RDW-CV:11.9
RDW-SD:38.5
RBC count:4.92million/cumm
Platelet count:1.65 lakhs/cumm
Renal function test:
Urea: 24mg/dl
Creatinine:0.9
Uric acid:4.0
Calcium:9.6
Phosphorus: 3.2
Sodium:140
Potassium: 4.2
Chloride: 103
Provisional diagnosis: Gastroenteritis -?Toxin mediated
TREATMENT GIVEN
1) IV FLUIDS 2NS @75ML/HR
2) INJ.PCM 1GM IV/SOS
IF TEMP >101F
3) INJ OPTINEURON IN 100ML NS IV/OD
4) TAB.SPOROLAC PO/OD
5) TAB.PAN 40MG PO/OD
6) TAB.DOLO 650MG PO/sos
7) TAB. ZOFER 4MG PO/SOS
8) PLENTY OF ORAL FLUIDS
9) MONITOR BP,PR,RR,TEMP EVERY 4TH HOURLY
-09/07/2023
Ward: general medicine ward
Unit: 6
DOA: 08/07/2023
Dr Govardhani (pgy1)
Dr Nishitha (pgy2)
Dr Zain (SR)
S:
4 loose stools
No fever spikes
O:
Pt is conscious,coherent and cooperative
No signs of pallor,icterus,cyanosis, clubbing, lymphadenopathy, pedal edema.
Bp-120/80 mm of hg
PR-88 bpm
Temperature -97F
RR-16cpm
CVS-S1,S2 heard,no murmurs
RS-BAE present.NVBS present
CNS-NFND
P/A-Soft and non tender
A:
Gastroenteritis? -Toxin mediated
P:
1) IV FLUIDS 2NS @75ML/HR
2) INJ.PCM 1GM IV/SOS
IF TEMP >101F
3) INJ OPTINEURON IN 100ML NS IV/OD
4) TAB.SPOROLAC
5) TAB.PAN 40MG PO/OD
6) TAB.DOLO 650MG PO/SOS
7) PLENTY OF ORAL FLUIDS
8) MONITOR BP,PR,RR,TEMP EVERY 4TH HOURLY
-10/07/2023
Ward:general medicine ward
Unit:6
DOA:08/07/2023
Dr Govardhan(pgy1)
Dr Nishitha(pgy2)
Dr Zain(SR)
S:
2 loose stools
No fever spikes
O:
Pt is conscious, coherent and cooperative
No signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy,pedal edema.
Afebrile
Bp:120/80 mm of hg
PR:80 bpm
RR: 16cpm
Temperature -97F
Spo2-98
CVS -S1,S2 heard,no murmurs
RS-BAE present,NVBS present
CNS-NFND
P/A-Soft and non tender
A:
Acute diarrhea
P:
1) IV FLUIDS 3NS @75ML/HR
2) INJ OPTINEURON IN 100ML NS IV/OD
3)TAB.SPOROLAC PO/TID
4)TAB.DOLO 650MG PO/SOS
5) PLENTY OF ORAL FLUIDS
6)ORS SACHETS IN ONE LITER WATER-DRINK SIP BY SIP AFTER EVERY EPISODE OF LOOSE STOOL
7) MONITOR BP,PR,RR,TEMP EVERY 4TH HOURLY
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