65 yr old female with loose stools
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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.
Thisis a 65 year old female housewife hailing from Peddakaparthy in Telangana who came to the OPD with chief complaints of loose stools.
Chief complaints:Patient was brought to casuality on 23/11/22 at 4:00 am early in the morning with complaints of loose stools since 5 days and pain as mentioned by the atttender as she was screaming and restless with altered sensorium.
History of presenting illness:
The patient was apparently asymptomatic 13 days ago.She passed loose stools- watery in consistency, foul smelling and blood tinged(4-5 episodes /day.She apparently consumed kaya churnam (an ayurvedic powder) , went to RMP nearby and was given medication, even then loose stools did not stop . The attender mentions she became weak and then on 23rd nov, apparently after eating curd rice , when patient slept , suddenly in the middle of night patient was screaming due to pain and could not talk anything. She was then bought to casuality.
History of past illness:
Apparently, a few yrs back in 2009, she slipped and fell in bathroom and was in a confused state for 10 to 15 days and during that period couldnt recognize anyone and couldnt talk and later when she was conscious, she could recognize their family members and diagnosed with hypertension. But since then, she restricted herself to bed and didnt walk much due to fear of falling down and didnt do much work.
She is going for regular checkups once in every 3 months for BP, and weakness.
N/k/c/o Diabetes, TB or asthma., CAD, epilepsy
Addictions:
. None
Family history : His husband was a diabetic who passed away .Eldest son is also diabetic
Surgical history: Hysterictomised 15 yrs ago
Treatment history : Telmisartan, vit D3 , Ca2+
Personal history :
Daily routine : Patient would wake up at 6am and would have chai , biscuits , take a bath.She would have her breakfast at 8 am and would then lie down.She would have her lunch at 12 30 PM and the attender mentioned she would have a lot of water of about 4 litres per day and sleep in the afternoon and in the evening she would talk to her grandkids and have curd rice for dinner by herself and would sleep by 10. Since 2 yrs she has not been sleeping properly and would manage only 2 - 3 hrs sleep in night. Since 5 - 6 days she is eating curd rice only
Diet: mixed
Appetite : decreased
Sleep : inadequate
Bowel movements : increased since 13 days
General examination: patient was examined after taking consent from the attenders.
Pt in not cooperative and coherent qnd ia irritable.
Pallor - present
Icterus- absent
Cyanosis- absent
Clubbing- absent
Koilonychia - absent
Lymphadenopathy - absent
Edema - grade 1 pedal edema
Vitals at presentation
Bp-110/80mm Hg
PR-104 bpm
Respiratory rate : 17/min
SpO2 : 97%
Temperature : Afebrile
Systemic examination :
CVS :
No thrills, no parasternal heave,
S1, S2 +, no murmurs
Respiratory system :
.BAE +
Trachea is central in position, no dyspnoea, no wheeze, vesicular breath sounds heard
Abdomen examination :
Non tender , bowel sounds heard
CNS :
Oriented to person,timme and place.
Repeatation : absent
Recall: absent
Language : absent
GCS : E4 V4M6
TONE : LT RT
U/L. Normal. Normal
L/L. Normal. Normal
Power :
U/L 3/5 3/5
L/L 3/5 3/5
Reflexes:
Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. - -
Ankle ++ ++
Plantar F F
Speech - normal
Signs of meningeal irritation - not present
Investigations :
Provisional diagnosis :
Altered sensorium 2° to Hyponatremia (Hypovolemic Hyponatremia)(True Hyponatremia) secondary to GI loss? Dysentery with Anemia under Evaluation.
Treatment
1.INJ. NS @ 75 ml/hr
2.INJ. METRONIDAZOLE 500 MG /IV/TID
3.INJ. PAN 40 MG /IV/OD
4.IVF-ZOFER 4mg /IV/SOC
5. ORS sachet 1 in 1 litre of H20 . Drink after each episode of loose stools
6. TAB SPOROLAC - DS / FO/TID
7. Ryles tube insertion
8. INJ. Metrogyl 100ml/iv/TID
9. Head end elevation
10 . INJ. Monocef 1gm/IV/TID
11.Change posture 2 hourly.
12.SYP POTCHLOR 15ML in 1glass of water.
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