Skip to main content

50yrs old female with acute gastroenteritis

   N.sahithi

   roll no :96

October 01, 2021

50 YR OLD FEMALE WITH ACUTE GASTRITIS

 

A 50 year old female came to the casuality on 28/09/21 with chief complaints of :

1. Pain abdomen since 2 hours 

2. Vomiting since 2 hours

3. Loose stools since 2 hours 

HOPI:

Patient was apparently asymptomatic 2 hours back when she developed pain abdomen, more in the right iliac fossa, which was sudden in onset and gradually progressive, a/w vomiting( 2 episodes), non bilious, non projectile.

Complaint of loose stools, 3 episodes in a day, non foul smelling, non blood tinged.

PAST H/O:

A k/c/o diabetes Mellitus and hypertension since 10 years.

Patient was previously admitted in General Medicine Department  on 7/9/21

Last dialysis 15 days back 

VITALS:

Temp- 98.5 F

BP- 140/80 mmhg

PR- 99

RR- 18 cpm

GRBS- 323 mg/dl

SpO2- 99% at room air 

O/E:

CVS- S1 S2 + No murmurs 

RS- BAE + NVBS

CNS- NAD

P/A- Soft, Tenderness present in epigastric region 



PROVISIONAL DIAGNOSIS:

Acute Gastroenteritis 

INVESTIGATIONS:


USG Impression:

Rt moderate hydronephrosis

Raised echogenicity of both kidneys.

Internal echoes in urinary bladder.

Lt simple renal cortical cyst.

DIAGNOSIS:

Pre Renal AKI on ? CKD ( secondary to Acute GE) with k/c/o DM since 10 years

K/c/o HTN since 10 years with Rt Diabetic foot.

Treatment:

DAY 1:


1. Intravenous fluids- RL, NS at 50ml/hr

2. Inj. METROGYL 500mg/IV /TID

3. Inj TRAMADOL 1 ampule in 100ml    NS/IV/SOS

4. Inj HAI Pre meal s/c  TID

     8AM-2 PM-8PM

5. Tab PAN 40mg PO/OD

6. Tab ZOFER 4mg PO/SOS

7. Inj. Vancomycin 1g in 100 ml NS / IV/ slowly through central line over 1 hr 

8. ORS Sachet in 1 litre of water to drink throughout the day after each stool.

9. GRBS Monitoring 6th hourly



DAY 2:

IVF - RL, NS @ 50 ml/hr

Inj. Metrogyl 500 mg IV/TID

Inj. Tramadol 1 amp in 100 ml NS / IV/ SOS

Inj HAI Pre meal/ SC/ TID

Tab. Odenseteron 4 mg / PO/ SOS

Tab. PAN 40 mg PO/ OD

Tab Zofer 4 mg / SOS

Daily dressing for diabetic foot 

ORS Sachet after each episode of loose stool.

GRBS charting 8th hourly 


Day 3:


1. Intravenous fluids- RL, NS at 50ml/hr

2. Inj. METROGYL 500mg/IV /TID

3. Inj TRAMADOL 1 ampule in 100ml NS/IV/SOS

4. Inj HAI Pre meal s/c  TID

     8AM-1PM-8PM

5. Tab PAN 40mg PO/OD

6. Tab ZOFER 4mg PO/SOS

7. Dressing for Diabetic foot done 

8. GRBS Monitoring 8th hourly


Day 4: 

1. Intravenous fluids- RL, NS at 50ml/hr

2. Inj. METROGYL 500mg/IV /TID

3. Inj TRAMADOL 1 ampule in 100ml NS/IV/SOS

4. Inj HAI Pre meal s/c  TID

     8AM-1PM-8PM

5. Tab PAN 40mg PO/OD

6. Tab ZOFER 4mg PO/SOS

7. Dressing for Diabetic foot done 

8. GRBS Monitoring 8th hourly

Patient shifted from AMC to Ward 


Day 5

S : Patient complaining of back pain since morning, 1 episode of loose stools in the morning

O :

Pt c/c/c

Temperature : 98.2 F

BP : 130/80mm Hg

PR : 97bpm , regular

GRBS : 208mg/dl at 8AM

CVS : S1 S2 +, no murmur

RS : NVBS + , no crepts

P/A : soft, non tender

Hb- 7.4

TLC - 13,100

PLC-. 2,70,000

PCV- 22.1

RBC - 2.7


A :

Pre renal AKI ? CKD

Secondary to Acute Gastroenteritis with k/c/o DM, 

K/c/o Hypertension since 10 years with right Diabetic foot.


P : 

1. Intravenous fluids- RL, NS at 50ml/hr

2. Inj. METROGYL 500mg/IV /TID

3. Inj TRAMADOL 1 ampule in 100ml NS/IV/SOS

4. Inj HAI Pre meal s/c  TID

     8AM-1PM-8PM

5. Tab PAN 40mg PO/OD

6. Tab ZOFER 4mg PO/SOS

7. Dressing for Diabetic foot done 

8. GRBS Monitoring 8th hourly 






Comments

Post a Comment

Popular posts from this blog

65 yrs female came with low back ache and decreased urine out put

Image
  Sahithi nalabolu  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.   This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box" Hall ticket number: 1701006124 Final examination short case: Case presentation: A 65 year old female patient came to the hospital with the  Cheif complaints :  •Low back pain since 7 days   •Redued urine output since 7 days  History of Presenting Illness:  Patient was apparently asymptomatic 4 years ago then she developed low back pain of cramping type aggravated on working and was relieved on medications .  Since then, she used to t...
Read more

A 27yrs old male came to casuality with c/o headache

Image
  Sahithi.N 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  Case history: Cheif complaints: . A 27yrs old male came to casuality with c/o headache  and giddiness on and off since 3yrs HOPI:  Patient was apparently asymptomatic 3yrs back then he sustained...
Read more

Internship assessment

  INTERNSHIP ASSESSMENT  Sahithi Nalabolu  June 15, 2023 I have been posted in General Medicine  from  14th April to 12 th june FIRST 15 DAYS UNIT DUTIES (12-02-2023 TO 26/02/2023) NEXT 15 DAYS PSYCHAITRY (27/02/2023 TO 13/03/2023) NEXT 15 DAYS PERIPHERALS (14/03/2023 TO 29/03/2023) LAST 15 DAYS UNIT DUTIES (29/03/2023 TO 13/04/2024) UNIT DUTY :  I have been posted intially into unit  Op duties: Attended my all the 4 op duties and Audit duties I took history of many  patients and examined them clinically. Learnt basic management for common conditions like Hypertension,Diabetes mellitus,chest pain , migrane . And I made PaJR groups and blogs for admitted patients. Blog 1: https://sahithinalaboluelog.blogspot.com/2023/05/45-yr-old-male-with-abdominal.html A 45 years old male came with   -c/o Abdominal distension since 4months - SOB On  and off  since 4 months Learning points: Ascitic tap  Learnt about SAAG  Learnt the causes...
Read more