ACUTE GE WITH AKI

 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.


CHIEF COMPLAINTS
A 48 yr old female, Daily wage labourer by occupation , Resident of nalgonda came with chief complaints of
• Loose stools since 3 days
• Vomiting since 2 days
• Decreased urine output since 1 day


HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 3 days back and then she developed loose stools 5-6 episodes per day , watery , non mucoid, non blood stained.

She also complains of vomiting 4- 5 episodes per day ,(after she consumes food), food as contents , bilious , nonprojectile.

History of mutton consumption 4 days back

No history of fever, burning micturition, cough, cold, shortness of breath.


PAST HISTORY

Not a known case of Diabetes, Hypertension,  Asthma, Epilepsy, Tuberculosis.
No history of hospital admissions or surgeries


FAMILY HISTORY
No significant family history


PERSONAL HISTORY

Diet- Mixed
Appetite- Reduced
Sleep- Disturbed
Addictions- None

GENERAL EXAMINATION

Patient is conscious, coherent, cooperative
Moderately built and moderately nourished
Well oriented to time ,place and person

Pallor: present
Icterus: absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy : absent
Edema: absent

Decreased skin turgor

VITALS

On 17/3/22
Temperature : 98.6 f
Pulse rate: 82 bpm
Respiratory rate : 24 cpm
Blood pressure: 140/80mmhg
GRBS : 164mg/dl
SPO2: 99%

On 19/3/22
Temperature: 98 f
Pulse rate: 76 bpm
Respiratory rate: 20 cpm
Bloodpressure: 140/80 mmhg
Sp02: 98%
GRBS: 120 mg/dl


SYSTEMIC EXAMINATION

RS : BAE+, NVBS
PA: Soft, non tender
CVS: S1 S2 heard,  no murmurs
CNS: NFD


INVESTIGATIONS

PH : 7.08
PCo2 : 15.3
PO2: 113
HCO3: 7.1


Urea: 112
Creatinine: 5.4
Na: 138
K: 3.3
Cl: 101

Hb: 9.2
TLC: 13100
PCV:  28.3
Platelets:  2.78 
N/L/M/E/B: 86 /8 /2 /4 /0












PROVISIONAL DIAGNOSIS
Acute gastroenteritis with AKI


TREATMENT

●BP, PR, TEMP monitoring 
● Inj MONOCEF 1gm IV BD
● IV RS, NL, DNS @ 150ml/hr
●Plenty of oral fluids
● Inj Metrogyl  100ml IV TID 
●Inj lasix 20mg IV BD
●Syp Potchor 10 ml in 1 glass water BD
●Tab Sporolac TID




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