A 85 Y/O MALE WITH LOOSE STOOLS

 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 plan.

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever .

A 85 year old male who is a resident of Miryalguda,Nalgonda and was farmer by occupation presented to the OPD with

CHIEF COMPLAINTS :

• decreased appetite since 5 days
• passage of loose stools since 5 days
  

HISTORY OF PRESENTING ILLNESS : 

                          Patient was apparently asymptomatic 5 days ago,then he started passing loose stools which was acute in onset, non progressive, no odour, not blood tinged, loose in consistency 9-10 times a day, no aggravating or relieving factors

no history of pain abdomen

no history of nausea or vomitings

no pus in the stools.

PAST HISTORY:

no history of diabetes, asthma, epilepsy, tb, thyroid disorders

h/o some kidney cyst for which he had undergone surgery in which they removed left kidney 7 years ago.

k/c/o HTN since 5 years

PERSONAL HISTORY:

patient was farmer by occupation, but he gave his land for someone else to farm.He wakes up at 5-6 in the morning takes mixed diet. Patient had some swelling on his left toe for which he used traditional medicine and some OTC pain killers for 6 years, still the pain did not subside and he went to some local RMP. RMP cut that hard swelling.  

patient has irregular bowel movements and normal bladder movements

He used to smoke BD and cigarettes, consumed alcohol and stopped 15 years ago.

TREATMENT HISTORY: metaprolol 50mg for HTN, one dialysis is done today.
 

ALLERGIC HISTORY: n/a 

GENERAL EXAMINATION: 

Patient is conscious, non coherent, non cooperative not well oriented to time,space and person.

Pallor -.present

     Icterus -present

     Clubbing - Absent

     Cyanosis - Absent

     Lymphadenopathy -Absent

    

VITALS:

      PR - 80beats per min

      RR - 23 cycles per min

      BP -  100/60 mm of Hg

      Temp -99.8 F

      SPO2- 98% 

 

SYSTEMIC EXAMINATION:

 

CVS: S1 S2 heard, no murmurs heard

RESPIRATORY SYSTEM:  normal vesicular breath sounds + bilateral air entry+

PER ABDOMEN: not performed, patient was non cooperative

CNS: not performed, patient was non cooperative

 

INVESTIGATIONS:

DIAGNOSIS: Uremic encephalopathy due to kidney failure ? secondary to nsaid abuse

03/09/2022- patient developed psvt given adenosine and developed cardiac arrest, defibrillation done, heart rate came back to normal

O2 saturations dropped, patient went into metabolic acidosis, intubation is done

after 20 mins he developed a ventricular tachycardia and ventricular failure; followed by cardiac arrest and a flat line ecg

declared dead at 8:48 PM