50 yr Male with Chronic diarrhoea and RVD positive
50 year old male with Chronic diarrhoea (Newly detected RVD+)
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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.
A 50/M farmer by occupation came with
• c/o fever , cough, loose stools since 30 days
• c/o loss of appetite, decreased sleep & reduced weight since 20 days
HOPI
pt was apparently asymptomatic 30 days back then he developed fever which is low grade, intermittent associated with chills and rigor , not associated with headache , nausea and vomiting.
Cough - Initially it was dry cough , since 10 days he is getting sputum while coughing
Loose stools - watery in consistency , green to yellow in colour, multiple episodes , immediately after food intake , tenesmus+, ,high volume ,not associated with pain abdomen and vomitings
Not associated with blood , mucous , steatorrhea
Personal history
Decreased appetite
Diet - Non vegetarian
Bowel and bladder - loose stools
Micturition - normal
No addictions
O/E
Height - 170 cm
Weight -38 kg
Pallor +,
No icterus , cyanosis ,clubbing,
VITALS
Temp -afebrile
bp - 70/60 mmHg
PR - 110 bpm
RR - 20
Spo2 - 100
RS - BAE + , coarse crepts rt side , lower ICA+, ISA+, IAA
CVS -S1, S2 +
P/A - SOFT
Rx
1. IVF - NS, RL @ 75 ml/hr
2. Inj . METROGYL 100 ML/IV/ TID
3. INJ. PANTOP 40 mg /IV/OD
4. Tab. CIPROFLOXACIN 400 MG/ PO/ BD
5. Vitals monitoring
Investigations
RETRO VIRAL DISEASE+
SOAP NOTES
DAY 1
Subjective- loose stools 2 episodes, mild cough.
Objective
Temp: Afebrile
Bp: 70/50 mm hg
@10am 100/60.
PR: 92 bpm
GRBS: 92 mg/dl.
Assessment
CHRONIC DIARRHOEA
Newly detected ( RVD +)
Plan of care:
-IVF NS,RL @ 75ml/hr.
-Inj. METROGYL 100mL IV/OD.
-Inj.PAN 40 mg IV/OD
-Tab.CIPROFLOXACIN 400mg PO/BD.
-Tab.BACTRIM DS PO/OD.
4th hrly vitals monitoring.
-Temperature charting.
DAY2
Subjective- loose stools 4 episodes- watery, green in consistency , mild cough.
Objective
Temp: Afebrile
Bp: 100/70 mm hg.
PR: 82 bpm
GRBS: 98 mg/dl.
Assessment
CHRONIC DIARRHOEA
Newly detected ( RVD +)
Plan of care:
-IVF NS,RL @ 75ml/hr.
-Inj. METROGYL 100mL IV/OD.
-Inj.PAN 40 mg IV/OD
-Tab.CIPROFLOXACIN 400mg PO/BD.
-Tab.BACTRIM DS PO/OD.
Tab.SPOROLAC DS PO/OD.
SYP. GRILINICTUS 15ML/PO/TID.
ORAL SACHET in 1L of water
4th hrly vitals monitoring.
-Temperature charting
Soap notes
DAY3
Subjective- loose stools 5 episodes- green in colour and watery in consistency ,
4 episodes of vomiting green in colour, cough
Objective
Temp: Afebrile
Bp: 110/80 mm hg.
PR: 68 bpm
GRBS: 105 mg/dl.
Assessment
CHRONIC DIARRHOEA
Newly detected ( RVD +)
Plan of care:
-IVF NS,RL @ 75ml/hr.
-Inj. METROGYL 100mL IV/OD.
-Inj.PAN 40 mg IV/OD
-Tab.CIPROFLOXACIN 400mg PO/BD.
-Tab.BACTRIM DS PO/OD.
Tab.SPOROLAC DS PO/OD.
SYP. GRILINICTUS 15ML/PO/TID.
ORAL SACHET in 1L of water
4th hrly vitals monitoring.
-Temperature charting.
