A 55 year old male with Acute dysentery
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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 55 year old male farmer by occupation came to casualty with
C/o loose stools since5 days- 6 to 8 episodes/day ,small volume,watery in consistency
Pt had h/o one day fever(low grade, intermittent in onset),which subsided after taking medication.
Pt c/o pain abdomen on consuming food which is colicky type, intermittent,not radiating later on from past 2 days patient experiencing frank blood while passing stools(1- 2 episodes/ day)along with watery stools.
H/o weight loss present
H/o outside food consumption 5 days back
No h/o vomitings
No h/o piles
No h/o cough,cold,sob
No h/o burning micturition,hemoptysis,melena
Past history:
no h/o HTN, DM,TB, Epilepsy,asthma
Personal History:
Diet:mixed
Appetite: decreased
Sleep: decreased
Occasional alcoholic
No tobacco use
Family history: Not significant
GENERAL EXAMINATION :
Patient is conscious, coherent and cooperative
Moderately built and moderately nourished
No pallor,icterus,clubbing,cyanosis,koilonychia,edema and lymphadenopathy
VITALS :
Temp: afebrile
PR: 90 bpm
BP: 140/90 mm hg
Spo2 - 99% at RA
CVS :
S1, S2 heard , No murmurs
RS :
Position of trachea: central
Bilateral decreased air entry +
PER ABDOMEN:
Abdomen is soft and mild tenderness + in hypogastrium
Bowel sounds heard.
CNS:
Patient is Conscious ,oriented to time,place and person
HMF -intact
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
No meningeal signs
PROVISIONAL DIAGNOSIS:
Acute dysentery
Investigations
Surgery refferal
Proctoscopy
Treatment
On 19/9/21
1.Inj.metrogyl 400 mg/iv/tid
2.inj.MVT in100 mlns/iv/od
3.IVF -NS@100 ML/HR,DNS@Overnight
4. Temp Charting 4 th HRLY
5.BP/PR/SPO2 MONITORING 2ND HRLY
On 20/9/21
SOAP NOTES
A 55 YEAR OLD MALE
SUBJECTIVE
Pain abdomen decreased
1 episode of stool associated with blood
OBJECTIVE
Pt is c/c/c
Temp: afebrile
BP: 130/70 mm Hg
PR: 78 bpm
CVS: s1, s2 heard
CNS: NAD
RS: NVBS +
GRBS:83 mg/dl
ASSESSMENT-
Acute dysentery
PLAN OF TREATMENT-
1.IVF NS,RL,DNS@ 150 ml/ hr
2.INJ.pantop 40 mg iv/od
3.INJ.zofer 4 MG IV/sos
4. Inj.tramadol 1 amp in 100 ml Ns IV/ tid
5. Tab.pcm 500 mg po/ sos
6. Inj.metrogyl 400 mg/iv/tid
7. Monitor vitals 4 th HRLY
8. I/O charting
On 21/9/21
SOAP NOTES
A 55 YEAR OLD MALE
SUBJECTIVE
Pain abdomen Subsided
No episodes of loose stools
OBJECTIVE
Pt is c/c/c
Temp: afebrile
BP: 120/80 mm Hg
PR: 84 bpm
CVS: s1, s2 heard
CNS: NAD
RS: NVBS +
GRBS:105 mg/dl
ASSESSMENT-
Acute dysentery
PLAN OF TREATMENT-
1.liquid diet
2.IVF NS,RL,DNS@ 150 ml/ hr
3.INJ.pantop 40 mg iv/od
4. TAB.Ultracet po/sos
5. Tab.pcm 500 mg po/ sos
6. Monitor vitals 4 th HRLY
7. I/O charting
8.GRBS-6th hrly
On 22/9/21
SOAP NOTES
A 55 YEAR OLD MALE
SUBJECTIVE
No episodes of loose stools
OBJECTIVE
Pt is c/c/c
Temp: afebrile
BP: 150/80 mm Hg
PR: 88 bpm
CVS: s1, s2 heard
CNS: NAD
RS: NVBS +
ASSESSMENT-
Acute dysentery
PLAN OF TREATMENT-
1.Soft diet
2.IVF NS,RL,DNS@ 150 ml/ hr
3.INJ.pantop 40 mg iv/od
4. TAB.Ultracet po/qid
5. Tab.pcm 500 mg po/ sos
6. Monitor vitals 4 th HRLY
7. I/O charting
8.GRBS-6th hrly
