50yrs old female with acute gastroenteritis
- Get link
- Other Apps
N.sahithi
roll no :96
"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
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
- Get link
- Other Apps
Comments
Post a Comment