59 yr old male with 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 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.


CHIEF COMPLAINTS 

A 59yr old male came with C/o Fever associated with chills and rigor since 4 days .

Loose stools since 4 days

Vomitings 3 days back 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 4days ago then he developed high grade fever which was intermittent in natureassociated with chills and rigors followed by several episodes of loose stools which were liquid in consistency large volume yellow coloured not blood stained and not foul smelling associated with abdominal pain.he also had  5 episodes of vomiting 3days back which was non projectile, contents are food particles and water, non foul smelling.








PAST HISTORY 

He had similar complaints 3 yrs ago and got admitted in the hospital.

H/O DM  3 years back ( he took Metformin BD for 3 months 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:101°F
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

Fever chart

ECG

INVESTIGATIONS 









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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