50yrs old female with acute gastroenteritis
N.sahithi
roll no :96
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
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