A 55 year old male with loose stools
Medical case discussion
A 55 year old male farmer by occupation came to casualty with chief complaints of loose stools since 2 days
Chief complaints of 15 episodes of loose stools since 2 days .
History of present illness :
Patient was apparently asymptomatic 2 days ago then he gives alleged h/o sunstroke 2 days ago,then he has h/o alcohol intake and outside food consumption on that day, following which he had 15 episodes of loose stools which are involuntary and watery in consistency, yellowish white
1 episode of vomiting, sudden in onset , non bilious, non foul smelling, non blood tinged , non projectile .
Not associated with nausea, headache.
low grade fever , continuous, sudden in onset, non progressive, not associated with chills and rigor.
No h/o sob,chest pain, palpitations , syncope
No h/o Pedal edema ,distension of abdomen .
No burning micturation.
Past history : not a known case of hypertension, diabetes mellitus , asthma, CVA.
Family history: no significant family history
Personal history: mixed diet, normal appetite, adequate sleep and regular bowel and bladder moments and bowel and bladder moments changed past 2 days
Addictions:- drinks 90 ml alcohol 2-3 times a week since 20 years
Treatment history: no history of taking medication
General examination
Patient is conscious coherent cooperative, well build and nourished.
Pallor present, icterus,cyanosis, clubbing, generalized lymphadenopathy, bilateral pedal edema absent
Vitals:-
BP- 60/40 mmhg
PR- 63bpm
RR:- 45 cpm
Spo2:- 99% @RA
GRBS:- 157 gm/dl
Systemic examination
Per abdomen:
Inspection:
Round, large with no distention
Umbilicus: Inverted and central
No visible pulsation,peristalsis, dilated veins and localized swellings.
Palpation:
No local rise of temparature ,tenderness present in epigastric region
No signs of organomegally
Percussion:
No fluid thrill, shifting dullness absent
Auscultation:
Bowel sounds heard 10/minute
CVS:
Inspection:
There are no chest wall abnormalities
The position of the trachea is central.
Apical impulse is not observed.
There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses.
Palpation:
No local rise of temparature and no tendersness
Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line
Position of trachea was central
Auscultation:
S1 and S2 were heard
There were no added sounds / murmurs.
RESPIRATORY SYSTEM:
Bilateral air entry is present
Chest appears to be elliptical and bilaterally symmetrical.
No scars and sinuses or engorged veins seen .
Normal vesicular breath sounds are heard.
Chest movement increased tacheypeina
CNS:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES :Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION:
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
CEREBELLAR FUNCTION:
Normal function
No meningeal signs were elicited
Provisional diagnosis:-
Hypovolemic shock 2° to ? dehydration 2° to GI losses ( gastro enteritis ) with acute kidney injury ? Pre renal ? Renal With ? heart failure (Rt)
Investigation;-
Final Diagnosis:-
Hypovolemic shock secondary to gastroenteritis
Treatment:-
1.IV fluids NS,RL @ 50-70 ml/hr
2.Inj NORADRENALINE (2 amp + 46 ml NS) @ 5ml/hr increase or decrease to maintain map > 65 mmhg
3.Inj monocef 1g/iv/bd (day 2)
4.Inj lasix 20 mg/iv/bd( if MAP >65MMHG)
5.Inj thiamine 200 mg in 100 ml NS over 30 minutes/iv/od
6. Ecosprin AV75/IO/po/hs
7. tab dolo 650 mg/po/sos( temp >100°F)
8.monitor vitals hourly
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