A 55 year old male patient with Acute dysentery

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.

A 55 year old male farmer by occupation came to casualty with loose stools since 1 week.

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 week back . Then he c/o loose stools since 1 week- 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 also c/o pain abdomen on consuming food which is colicky type, intermittent,not radiating later on from past 4 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 1week 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.
Nopallor,icterus,clubbing,cyanosis,koilonychia,edema and lymphadenopathy.  

VITALS : 
Temp: afebrile 
PR: 90 bpm 
BP: 140/90 mm hg 
Spo2 - 99% at RA  

SYSTEMIC EXAMINATION:
CVS : 
S1, S2 heard , No murmurs 

RESPIRATORY SYSTEM:
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:
Complete blood picture:
Hemoglobin-13.8 gm/dl
TLC-12900
Platelet count-3.58 lakhs/cu.mm










Treatment:

Day-1:
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

Day-2:
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

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