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A CASE OF 22 YR OLD MALE

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's  consent.

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box below.

Note : This is an ongoing case and will be updated regularly. 

Date of admission: 08/07/2023 

A 30 year patient, farmer by occupation came to casualty with complaints loose stools since 1 day 

Patient was apparently asymptomatic one day ago when he had consumed food (fried rice) from a new place after which he developed 27-28 episodes of loose stools.

The stools were large in quantity losse in consistency and non foul smelling 

Associated with complaint of burning micturition since one day

No Associated discolouration of stools,no decrease in urinary output, no blood in urine and stools, pus in urine seen 

Associated with diffuse abdominal pain 

Associated with high grade fever, intermittent duration 

No Associated rigor, chills, cough, SOB, sore throat 

Past history: 

The patient is not a known case of Diabetes/ hypertension/ asthma /TB/ CKD/CVD/Thyroid disorders

No h/o any blood transfusions 

No h/o surgery 

Personal History: 

DIET: mixed 

APPETITE: decreased 

SLEEP: adequate 

BOWEL AND BLADDER MOVEMENTS : 20- 25 episodes of loose stools per day 

ADDICTION: occasional consumption of alcohol 

ALLERGY :nil 

Treatment history: Not significan

Family history: Not significant 

Consent: Consent was taken from patient before Examination 

General Examination:

Patient is conscious, coherent, cooperative and well oriented to time, place and person 

Moderately built andnourished 

No pallor, icterus, cyanosis, clubbing, koilonychia, pedal edema, bilateral lymphadenopathy

Vitals: on 08/07/2023 

•BP- 120/70 mmhg 

•Pulse- 64 bpm

•Respiratory rate- 16Cpm

•SpO2- 96%

•Temperature - 101°F

Systemic Examination: 

Abdominal Examination 

•Inspection

Truncal obesity is seen 

Position of umbilicus: central and inverted 

No Scars and sinuses , visible pulsations 

No visible peristalsis 

No engorged veins 

•Palpation

No tenderness 

No local rise of temperature 

No organomegaly seen 

•Auscultation

Bowel sounds are heard 




CVS 

S1,S2 heard 

No murmurs 

Respiratory system 

BAE present 

NVBS  heard 

CNS 

Reflexes are intact 

No functional deficit seen 

Provisional diagnosis: Gastroenteritis -?Toxin mediated

On 08/08/2023

Investigations

HEMOGRAM
Hb-14.5gm/dl
TLC-5,300cells/cumm
 Neutrophils:79
 Lymphocytes: 11
 Eosinophils:01
 Monocytes:09
 Basophils:00
PCV:42.4
MCV:88.3
MCH:30.2
RDW CV:11.9
RDW SD:38.9
RBC count:4.80
Platelet count:1.51lakh/cumm

COMPLETE URINE EXAMINATION
Colour:Pale yellow
Appearance:Clear
Reaction:Acidic
SP.gravity:1.010
Albumin:+
Sugar:Nil
Bile salts:Nil
Bile pigments: Nil
Pus cells:3-6
Epithelial cells:2-4
Red blood cells:Nil
Casts:Nil
Crystals:Nil
Amorphous deposits:Absent
Others:Nil

Blood urea: 26

Serum creatinine: 1.0

Hbs Ag RAPID:Negative

HIV 1/2 Rapid test:non
Reactive

LIVER FUNCTION TEST
Direct bilirubin:0.24gm/dl
Total bilirubin:0.86gm/dl
AST:27 IU/L
ALT:40 IU/L
Alkaline phosphatase:113 IU/L
Total protein: 6.4 gm/dl
Albumin:4.08 gm/dl
A/G Ratio:1.76

SERUM ELECTROLYTES
Sodium-141mEQ/L
Potassium -3.8 mEQ/L
Chloride-106 mEQ/L
Calcium-1.16 mmol/L

USG Abdomen: Borderline splenomegaly

TREATMENT: 
1) IV FLUIDS 2NS @75ML/HR
2) INJ.PCM 1GM IV/SOS
IF TEMP >101F
3) INJ OPTINEURON IN 100ML NS IV/OD
4) TAB.SPOROLAC PO/OD
5) TAB.PAN 40MG PO/OD
6) TAB.DOLO 650MG PO/sos
7) TAB. ZOFER 4MG PO/SOS
8) PLENTY OF ORAL FLUIDS 
9) MONITOR BP,PR,RR,TEMP EVERY 4TH HOURLY

On 09/7/23

Vitals:
Bp-120/80 mm of hg
PR-88 bpm
Temperature -97°F
RR-16cpm

Investigations

RENAL FUNCTION TEST 
Urea-20mg/dl
Creatinine-1.1mg/dl
Uric acid-4.6mg/dl
Calcium-9.8
Phosphorus -2.9
Sodium-138
Potassium -3.6
Chloride -102mEq/l

Hemogram
Hb: 13.7gm/dl
TLC: 4,200cells/cumm
 Neutrophils:73
 Lymphocytes: 17
 Eosinophils-01
 Monocytes:09
 Basophils:00
PCV:40
MCV:88.3
MCH:30.2
MCHC:34.3
RDW-CV:11.9
RDW-SD:39.2
RBC-4.53 million/cumm
Platelet count -1.5 lakh/cumm

TREATMENT: 
1) IV FLUIDS 2NS @75ML/HR
2) INJ.PCM 1GM IV/SOS
IF TEMP >101F
3) INJ OPTINEURON IN 100ML NS IV/OD
4) TAB.SPOROLAC PO/OD
5) TAB.PAN 40MG PO/OD
6) TAB.DOLO 650MG PO/sos
7) TAB. ZOFER 4MG PO/SOS
8) PLENTY OF ORAL FLUIDS 
9) MONITOR BP,PR,RR,TEMP EVERY 4TH HOURLY

On 10/07/2023 
 
Vitals:
Temperature: afebrile 
Bp:120/80 mmhg
PR:80 bpm
RR: 16 cpm
Temperature -97°F
Spo2-98 %@ room temperature

TREATMENT: 
1) IV FLUIDS 2NS @75ML/HR
2) INJ.PCM 1GM IV/SOS
IF TEMP >101F
3) INJ OPTINEURON IN 100ML NS IV/OD
4) TAB.SPOROLAC PO/OD
5) TAB.PAN 40MG PO/OD
6) TAB.DOLO 650MG PO/sos
7) TAB. ZOFER 4MG PO/SOS
8) PLENTY OF ORAL FLUIDS 
9) MONITOR BP,PR,RR,TEMP EVERY 4TH HOURLY


On 11/07/23

Vitals:
Temperature: Afebrile
Bp: 120/80mm of hg
PR: 84bpm
RR: 18cpm
Temperature -98.5°F
Spo2-98%@ room temperature 

Investigations 
Hemogram
Hb: 15.0gm/dl
TLC :4,000cells/cumm
 Neutrophils:40
 Lymphocytes: 48
 Eosinophils:02
 Monocytes:02
 Basophils:00
PCV:42.6
MCV:86.6
MCH:30.5
MCHC:35.2
RDW-CV:11.9
RDW-SD:38.5
RBC count:4.92million/cumm
Platelet count:1.65 lakhs/cumm

Renal function test:
Urea: 24mg/dl
Creatinine:0.9
Uric acid:4.0
Calcium:9.6
Phosphorus: 3.2
Sodium:140
Potassium: 4.2
Chloride: 103

TREATMENT: 
1) IV FLUIDS 2NS @75ML/HR
2) INJ.PCM 1GM IV/SOS
IF TEMP >101F
3) INJ OPTINEURON IN 100ML NS IV/OD
4) TAB.SPOROLAC PO/OD
5) TAB.PAN 40MG PO/OD
6) TAB.DOLO 650MG PO/sos
7) TAB. ZOFER 4MG PO/SOS
8) PLENTY OF ORAL FLUIDS 
9) MONITOR BP,PR,RR,TEMP EVERY 4TH HOURLY


                           FEVER CHART 


Date of discharge: 12/07/2023 


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