55 year male with hypovolemic shock

 

55 year old male with c/o 15 episodes of loose stools

April 17, 2023

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 

A 55 year old male farmer by occupation came to casualty with cheif complaints of loose stools since 2 days 

Cheif complaints of 15 episodes of loose stools since 2 days .

History of presenting 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;- 

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