64 /F 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

Investigations : 

Serum electrolytes on 23 rd nov

Serum electrolytes on 24 nov 2022

Hemogram on Nov 23

Hemogram on 24 nov 2022

ABG

FEVER CHART

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.