A 59 YEAR OLD MALE WITH LOOSE STOOLS ,VOMITINGS

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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 patient's 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 the comment box.

  A 59 Year old man came to  casuality with chief complaints of fever since one day associated with chills and rigor. He was 
also suffering with loose stools since yesterday ( several episodes of liquid consistency stools) and 5 episodes of vomiting since yesterday.

HOPI 

Patient was apparently asymptomatic 3 days back  then he developed high grade fever, intermittent  in nature which was associated with chills and rigors followed by several episodes of loose stools ( watery in  consistency),acute in  onset ,yellowish in colour  which were not blood stained and not foul smelling associated with abdominal pain and vomitings .he also had  5 episodes of vomiting non projectile in nature ,contents are food particles  and water,not blood stained,
past history : He had similar complaints 3 years back 

H/O DM  3 years back ( he was taking  Metformin and stopped )
Not a K/C/O Htn,asthma ,epilepsy,CAD,TB 

personal History  : 

DIET: Mixed
APPETITE: good
BOWEL AND BLADDER: regular
SLEEP: adequate
ADDICTIONS: none
Family history 
NO similar complaints in the family 
NO H/ O blood transfusions.

Previous history: 
he presented with similar complaints in the past at this hospital
And was treated with
Tab. Pan 40 mg od for 7 days
Tab. METFORMIN 500 mg for 7 days
Tab.bescoules od for 7 days
Inj. Ciprofloxacin 500 mg IV BD for 5 days
Inj. Metrogyl 500 mg IV tid for 5 days
Inj. Optineruron 1 amp in 1ns iv OD
Tab. Sporlac -ds tid
Ors sachet in 1lit. Water
Grbs before breakfast, 2hrs after lunch and 2hrs after dinner.

He was also discovered to be HIV positive in this hospital.
GENERAL PHYSICAL EXAMINATION: 
patient is conscious,coherent ,cooperative well oriented to time ,place and person
he is moderately built and nourished 
vitals at time of admission:

BP: 100/70mmhg
PR:112 bpm 
Temp:101f
RR : 18 CPM
NO pallor,icterus ,clubbing ,cyanosis ,lympadenopathy ,edema
SYSTEMIC EXAMINATION:
PER ABDOMEN : 
shape of abomen is scaphoid,no scars ,sinuses,no hernial orifices,no 
tenderness on palpation , no organomegaly,
CNS : no focal neurological deficits
CVS : 
S1 ,S2 heart sounds heard ,no murmurs
RS: Normal vesicular breath sounds,no adventitious sounds, Bilateral air entry present


provisional diagnosis: ACUTE GASTROENTERITIS?














Treatment:
Inj. Neomol 1gm, if stat (if temp more than 101f)
Tab. Sportscaster DS PO TID
Tab pan 40MG PO OD 
IV FLUIDS NS @50 ml/hr
Tab dolo 650 mpg

GRBS monitoring 6th hourly 
BP, PR monitoring 12th hourly 
temp monitoring 4th hourly PO TID




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