Acute Gastro enteritis with acute bronchitis with DM and HTN.

 

72 yr old female with fever, vomitings and loose stools.

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 patient’s clinical problems with collective current best evidence-based inputs. This is the E-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome.

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 diagnosis and treatment plan.

September 22, 2021

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. 

Case:-

72yr old female  came to the casualty with c/o vomitings since 3 days, fever since 3 days loose stools since 1 day .

Fever : 

Low grade, intermittent, not associated with chills and rigors , associated with decreased Appetite, loose stools and vomiting.

Vomitings:- 

3-4 episodes per day, non - bilious , non - projectile, food/ water as content.

Stools:- 

10-12 episodes/day, green in colour associated with lower abdominal pain- diffuse, squeezing type, no aggrevating and relieving factors.

Patient was apparently asymptomatic 6 months back, from then she decreased using her left lower limb , walking with support (with wall/ stick).

She had intermittent episodes of vomiting since 6 months.

No bowel and bladder involvement.

K/c/o DM since 10 yrs.

K/c/o HTN since 10 yrs

Not a k/c/o asthma, TB, epilepsy, thyroid .

No surgical history.

O/E :-

Patient was c/c/c , 

No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy,edema.

Vitals:-

Temp: 100.2 F 

Bp : 130/70 mm hg

PR: 18 BPM 

Spo2 :- 99% @ RA

Grbs: 261 gm/dl 

Cvs:- S1,S2 heard, no murmurs .

Rs:- BAE present, 

Wheeze in left IAA present.

p/A:-

Obese, mild tenderness in lower abdomen in left hypochondrial religion.

CNS:-

Patient was conscious,

Speech - normal

No signs of meningeal signs.

Provisional diagnosis:-

Acute Gastro enteritis with acute bronchitis with DM and HTN.

 

Treatment:-

1. IVF NS, RL @ 150 ml/ hr.

2. Inj. Metrogyl 400 mg , iv/ tid.

3. Inj. Pantop 40 mg iv/od 

4. Inj. Zofer 4 mg iv/ sos

5. Neb. Budecort and duolin 6 th hrly.

SOAP

 Day 2:-

SOAP  

Day 2 

Subjective:-

Patient complains of fever , vomitings .

Objective-

Pt c/c/c ,

Febrile - 104.2 F

Bp : 140/60 mm hg

PR: 98bpm 

RR : 22 cpm 

Cvs : S1,S2 present.

Rs:-wheeze present in left IAA .

P/A:-

Soft, Mild tenderness present in right hypochondrium and epigastric reigion.

CNS :-

HMF intact.

Assessment:-

Acute GE with HTN and Dm - 2 with acute bronchitis.

Plan :-

1. IVF - RL , NS @ 150 ml/hr.

2. Inj. Metrogyl 400mg iv/od 

3. Inj. Pantop 40 mg Iv/od 

4. Inj. Zofer 4 mg iv/sos.

5. Tab. Sporolac - Ds po/od 

6. Tab. Pcm 650 mg po/tid

7. Neb.with budecort and duolin 6 th hrly.

8. Inj. Monocef 1 gm iv/bd.