60 year old female complaining of loose stools and vomiting

ERLA SAI SHASI REDDY

ROLL NO : 182

9th semester 

    This is online E log book to discuss our patient’s 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 available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

 

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 . 

60 year old female complaining of loose stools and vomiting since 3 days and no urine output since two days .

Following is a brief about the case,

(History as per date of admission).

CHIEF COMPLAINTS: 

A 60 year old female, daily wage labourer came to the Medicine OPD with complaints of:

• Loose stools, vomiting since 3 days.

• No urine output since 2 days.

HISTORY OF PRESENT ILLNESS:

Patient is a daily wage labourer since 15 years.

Seven days ago she gave a history of mutton consumption. 

4 days later, the patient came with complaints of 

Loose stools 5 -6 episodes/ day, watery in consistency, non mucoid, non bloodstained, non foul smelling.

Vomiting 4-5 episodes, bilious, non projectile with food as content.

No urine output since 2 days.

No history of pain abdomen, fever, body aches, burning micturition, cough, cold and shortness of breath.

HISTORY OF PAST ILLNESS:

• There is no history of similar complaints in the past.

• She is not a known case of DM, HTN, ASTHMA,TB, EPILEPSY. 

• No history of surgeries in the past.

PERSONAL HISTORY: 

Appetite- normal

Diet -mixed

Sleep - disturbed

Bowel and bladder - increased bowel movements and no urine output

No addictions, no known allergies for food or drugs.

FAMILY HISTORY: 

No similar complaints in the family.

No significant family history.

GENERAL EXAMINATION:

Consent of the patient taken.

The patient is conscious,coherent and cooperative; well oriented to time,place and person.

She is moderately built and nourished.

• Pallor- present 

• Icterus - absent

• Clubbing - absent

• Cyanosis - absent

• Lymphadenopathy - absent

• Edema - absent

VITALS

Temp : 98.6 F

PR : 82 bpm 

RR : 24 cpm.

BP : 140/80 mm Hg

Spo2 : 97 %@ RA

Grbs : 107 mg/dl 

SYSTEMIC EXAMINATION: 

ABDOMEN EXAMINATION

INSPECTION:

Shape – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving with respiration.

No dilated veins, hernial orifices, sinuses

No visible pulsations.

PALPATION:

No local rise of temperature and tenderness

All inspectory findings are confirmed.

Deep palpation- no organomegaly.

PERCUSSION:

There is no fluid thrill , shifting dullness.

Percussion of liver for liver span

Percussion of spleen- dull note 

AUSCULTATION:

 Bowel sounds are heard.

CARDIOVASCULAR SYSTEM

INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses

Apical impulse and pulsations cannot be appreciated

PALPATION:

Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.

No parasternal heave, thrills felt.

PERCUSSION:

Right and left heart borders percussed.

AUSCULTATION:

S1 and S2 heard , no added thrills and murmurs heard.

RESPIRATORY SYSTEM

INSPECTION:

Chest is bilaterally symmetrical

Trachea – midline in position.

Apical Impulse is not appreciated 

 Chest is moving normally with respiration.

No dilated veins, scars, sinuses.

PALPATION:

Trachea – midline in position.

Apical impulse is felt on the left 5th intercoastal space.

Chest is moving equally on respiration on both sides

Tactile Vocal fremitus - appreciated 

PERCUSSION:

The following areas were percussed on either sides- 

Supraclavicular

Infraclavicular

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Upper/mid/lower interscapular were all RESONANT.

AUSCULTATION:

Normal vesicular breath sounds heard 

No adventitious sounds heard.

CENTRAL NERVOUS SYSTEM EXAMINATION.

HIGHER MENTAL FUNCTIONS:

 Patient is Conscious, well oriented to time, place and person.

All cranial nerves - intact

Motor system

                              Right.                  Left

BULK 

Upper limbs.        N.                         N

Lower limbs         N.                         N

TONE

 Upper limbs.       N.                        N

 Lower limbs.      N.                        N

POWER

 Upper limbs.      5/5.                    5/5

 Lower limbs      5/5.                    5/5

Superficial reflexes and deep reflexes are present , normal

Gait is normal

No involuntary movements

Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are     

                            well appreciated .

INVESTIGATIONS: 

HB : 9.2
TLC: 13,100
PCV:28.3
PLT:2.78
N/L/M/E/B: 86/8/2/4/0

Urea : 112
Serum creatinine :5.4
Na :138
K : 3.3
Cl : 101

PH : 7.08
Pco2:15.3
Po2: 113

Hco3: 7.1

Interpretation of ABG: high anion gap metabolic acidosis.

USG abdomen:

ECG:

PROVISIONAL DIAGNOSIS:

Acute GE with AKI.

TREATMENT:

1)IVF NS, RL,  DNS @ 150 ml / hr 
2)INJ. MONOCEF 1gm / i.v/ BD
3) INJ. METROGYL 100 ml /i.v/TID

4) inj. LASIX 20 mg i.v BD
5) Syp.potchor 10ml in 1glass water BD

6) Plenty of oral fluids.