68yr F with Vomitings and loose stools

THIS IS AN 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

Case History-
A 68 YR old Female came with chief  complaints of vomitings and loose stools since yesterday(19/06/2023) evening .

HOPI:
Patient was apparently asymptomatic till yesterday evening . She then had 6 to 9 episodes of vomitings from 6pm yesterday and 5-6 episodes of vomitings today(20/06/23) which are Non projectile , Non bilious , Non Blood tinged , Watery with food Particles  as contents.
She also had loose stools since evening of 19/06/2023 about 7 to 8 episodes which were Watery, foul smelling and non blood stained.
H/O eating Fish yesterday evening .
Not Associated with Pain Abdomen, Fever 
No H/O- Chest Pain, Palpitations, SOB, Decreased urine output and Pedal Edema.

Past History- 
Not a K/C/O DM, HTN,TB,Epilepsy,CVA, CAD, Bronchial Asthma, Thyroid Disorders .
H/O Surgery done 10yrs back  for Intestinal Perforation.

Personal History:
Diet- Mixed
Appetite- Decreased since  1 day
Bowel & Bladder Movements- Loose stools since 1 day &Regular urine output 
Sleep - Adequate
Addictions - None 

Family History - Not significant

GENERAL EXAMINATION-
Patient is Conscious, Coherent and Co operative .
No signs of Pallor ,Icterus Clubbing, Cyanosis, Lymphadenopathy and edema
Vitals-
TEMP: Afebrile 
BP: 100/70mmHg
PR: 104 bpm
RR- 26cpm
Spo2- 95% @RA
GRBS:147mg/dL

Systemic Examination:
CVS: Inspection
Chest wall is bilaterally symmetrical.
No precordial bulge is seen 

Palpation

JVP- Normal
Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 
Auscaltation-
S1&S2 are heard,no murmur found.

RESPIRATORY SYSTEM

Position of trachea- central
Bilateral air entry, normal vesicular breath sounds are heard.
No added sounds

CNS

Patient is conscious ,coherent and co operative , well oriented to time and space.
Speech normal.
No signs of meningeal irritation.
Motor and sensory system- Normal
Reflexes - present
Cranial nerves - intact



PER ABDOMEN

On inspection:
Abdominal distention - absent


All quadrants are moving equally with respiration
Umbilicus - central and inverted
No scars,dilated veins, prominent Venous pulsations and visible peristalsis.

On palpation::
Superficial palpation- No Local rise in temperature and no tenderness
Deep palpation- No guarding, rigidity


On percussion::
Tympanic note - heard 

No shifting dullness
On auscaltation::
Bowel sounds heard 

Provisional Diagnosis-
AKI?( Renal) Acute Gastroenteritis? 

Investigations-
SEROLOGY - Negative
RBS-
CUE-
Hemogram-
LFT-
RFT-
CXR

ECG-

Treatment-
1.IV Fluids - NS 
                   - RL
2.Inj.METROGYL - IV /TID
3.Inj.PAN 40mg IV/OD  
4.Inj.ZOFER 4mg IV/BD
5.Tab.SPOROLAC Po/TID
6.Tab.DOLO 650mg PO/SOS
7.ORS in 1L water 
8.Monitor Vitals 4th hrly



 




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