A CASE OF HYPOVOLAEMIC SHOCK SECONDARY TO ACUTE GASTROENTERITIS WITH ?LEFT LOWER LOBE CONSOLIDATION WITH ?AKI .
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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 a diagnosis and providing treatment best to our skills and wisdom.
A 40yr old patient who is a housewife presented to the casualty with complaints of fever, loose stools and vomitting .
Date of Admission: 06/06/2023
CHIEF COMPLAINTS
➤ High grade fever since 6 days
➤ Abdominal distension since 5 days
➤ Pain abdomen since 2 days
➤ SOB since 1 day
➤ Decreased urination since 1 day
➤ Loose stools and vomitting since 1 day .
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 6 days ago . Then she developed fever which is high grade , not associated with chills and rigor , intermittent type , relieved temporarily on medication.
Patient c/o vomitting since 1 day , 3-4 episodes of vomitings per day , contains food particles , non bilious , non projectile , associated with nausea .
She also has c/o of abdominal bloating since 1 day .
Also has c/o SOB which relieved by lying down .No c/o chest pain , orthopnea , PND .
She has c/o loose stools since 1 days , watery in consistency, 4-5 episodes , small in quantity, non blood stained, not associated with pain abdomen.
c/o epigastric pain since 1 day , insidious in onset , continuous and non radiating .
HISTORY OF PAST ILLNESS
➤ She has h/o hypothyroidism since 20 yrs .
➤ Not a k/c/o diabetes mellitus, HTN , TB apilepdy , asthma , CAD .
➤ k/c/o RA since 18 yrs (after childbirth)
DRUG HISTORY
Thyronorm 100 mcg PO/OD
PERSONAL HISTORY
➤Occupation: Housewife
➤Patient is married .
➤Patient takes a mixed diet and has a decreased appetite since 2 days .
➤Sleep : Regular
➤Bladder movements are normal , bowel movements increased
➤No known allergies .
➤ No known addictions.
➤ Surgical history - 1 LACS
FAMILY HISTORY
Not significant .
GENERAL EXAMINATION
➤Pallor : not seen
➤Icterus : not seen
➤Cyanosis : not seen
➤Clubbing : not seen
➤Lymphadenopathy : not seen
➤Edema : not seen .
VITALS
➤ Febrile
➤PR : 124 beats per minute
➤BP : 70 systolic palpatory .
➤RR : 18 cycles per minute
➤SpO2 : 96% in room air
➤ GRBS : 122 mg/dl
➤Blood Sugar (random) : 262 mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM EXAMINATION
➤s1 and s2 heard
➤Thrills absent.,
➤No cardiac murmurs
RESPIRATORY SYSTEM
➤Normal vesicular breath sounds heard.
➤Bilateral air entry present
➤Trachea is in midline.
ABDOMINAL EXAMINATION
INSPECTION
➤Shape - Obese
➤Equal movements in all the quadrants.
➤No visible pulsation, dilated veins and
localized swellings.
PALPATION
➤Liver , spleen not palpable.
➤ Epigastric tenderness .
CENTRAL NERVOUS SYSTEM EXAMINATION
➤Conscious and coherent
➤Speech : Normal
➤No signs of meningeal irritation
PROVISIONAL DIAGNOSIS: HYPOVOLAEMIC SHOCK SECONDARY TO ACUTE GASTROENTERITIS WITH ?LEFT LOWER LOBE CONSOLIDATION WITH ?AKI .
INVESTIGATIONS
TREATMENT
1) Inj. Piptaz 4.5gm iv/stat .
2) Inj. Piptaz 2.5gm iv/ TID.
3) IVF NS 100ml/hr
4) Inj. Zofer iv/BD
5) ORS 1 packet in 1L water 200 ml after every episode of loose stool .
6) Tab. Sporolac .
