INTRODUCTION:
A 80yr old female, housewife by occupation came to casuality with
chief complaints of :
fever since 1 day.
loose stools since 1 day.
Vomitings since 1 day.
HISTORY OF PRESENT ILLNESS:
Patient was asymptomatic 1 day back then developed a high grade intermittent fever , associated with chills and rigors which decreased on using medication with no diurnal variation.
Patient had loose stools;2 in number,
vomitings,3 in number, non projectile, smelled like raw meat(as described by the attenders and patient)
No h/o pain abdomen
no h/o cold and cough
no h/o burning micturition or decreased urinary output
HISTORY OF PAST ILLNESS:
Patient is a k/c/o Hypertension since 4 years
and is on telmisartan 12.5mg
patient is not a k/c/o of DM, asthma epilepsy, TB.
PERSONAL HISTORY:
bowel and bladder movements: normal.
appetite: normal.
non alcoholic.
non smoker.
Family history : No significant family history
GENERAL EXAMINATION:
patient is concious, coherent, cooperative well oriented to time and place
VITALS:
TEMPERATURE: 103F.
PULSE RATE: 96bpm.
BP:130/60mmhg.
RR:26cpm.
SPO2:97% at room air.
no pallor, icterus, cyanosis, clubbing, edema, generalised lymphadenopathy.
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
BAE+.
NVBS.
CVS :
S1S2 HEARD.
no thrills, no murmurs.
Per Abdomen:
Soft , non tender.
no palpable mass.
bowel sounds heard.
CNS:
All superficial and deep reflexes are normal.
INVESTIGATIONS:
HEMOGRAM
BLOOD UREASERUM CREATININE
SERUM ELECTROLYTES
ECG
USG ABDOMEN
Date:
Ward:AMC
Unit:2
Name of Treating Faculty
DR SAI RAGHU (INTERN)
DR LAXMI MAANASA (INTERN)
DR ROOPA (INTERN)
DR ACHAL RAM (INTERN)
DR RAVALI (INTERN)
DR VAMSI KRISHNA PGY1
DR RASHMITHA PGY2
DR NIKITHA PGY2
DR HAREEN (SR)
DR ARJUN KUMAR (AP)
DR RAKESH BISWAS (HOD)
Diagnosis AKI SECONDARY TO ACUTE GASTROENTRITIS WITH MEGALOBLASTIC ANEMIA
Case History and Clinical Findings
C/O FEVER ASSOCIATED WITH CHILLS SINCE YESTERDAY NIGHT HIGH GRADE INTERMITTENT ASSOCIATED WITH CHILLS, DECREASED ON USING MEDICATION
2 EPISODES LOOSE STOOLS WHICH DECREASED ON USING MEDICATION
3 EPISODES VOMITING WITH FOOD MATTER AS CONTENT , NON BILIOUS,NON PROJECTILE NO H/O PAIN ABDOMEN OR VOMITING
NO H/O COLD AND COUGH
NO H/O BURNING MICTURITION OR DECREASED URINARY OUTPUT
NO OTHER COMPLAINTS GENERAL EXAMINATION:
PATIENT WAS CONCIOUS,COOHERENT,COOPERATIVE,WELL ORIENTED TO TIME AND PLACE TEMPERATURE: 103F
PULSE RATE : 96 BPM
RR: 16cpm
BP: 130/60mmhg
SPO2: 96% at room air
GRBS : 126mg%
NO PALLOR,ICTERUS,KOILONYCHIA,CLUBBING,EDEMA,GENERALISED LYMPHADENOPATHY
SYSTEMIC EXAMINATION:
CVS: S1S2
HEARD NO THRILLS,MURUMURS RESPIRATORY SYSTEM:
NVBS HEARD
BAE +
PER ABDOMEN:
ABDOMEN SOFT NON TENDER NO PALPABLE MASS BOWEL SOUNDS +
Investigation:
1.HEMOGRAM
ON 03/08/2021
HB- 9.3gm/dl
TLC- 12,300 cells/cumm
PCV- 27.1 vol%
RBC COUNT- 2.43 millions/cumm
PLATELET COUNT- 2.40 lakhs/cu.mm
ON 05/08/2021
HB- 8.8 gm/dl
TLC- 9,100 cells/cumm
PCV- 25.5 vol%
RBC COUNT- 2.31 millions/cumm
PLATELET COUNT- 1.76 lakhs/cu.mm
ON 06/08/2021
HB- 8.7 gm/dl
TLC- 6,600 cells/cumm
PCV- 24.5 vol%
RBC COUNT- 2.25 millions/cumm
PLATELET COUNT- 1.74 lakhs/cu.mm
ON 07/08/2021
HB- 8.2 gm/dl
TLC- 5,200 cells/cumm
PCV- 23.0 vol%
RBC COUNT- 2.14 millions/cumm
PLATELET COUNT- 1.55 lakhs/cu.mm 2.COMPLETE URINE EXAMINATION ALBUMIN : NIL
PUS CELLS - 3-4
EPITHELIAL CELLS - 2-3
3.ULTRASOUND ABDOMEN AND PELVIS IMPRESSION:
B/L KIDNEYS RAISED ECHOGENICITY WITH GRADE 1 RENAL PARENCHYMAL CHANGE.
Treatment Given(Enter only Generic Name) On
1.IV FLUDS NS/RL - CONTINUOUS AT 100ML/HR 2.INJ.PAN 40 MG IV/OD FOR 3.INJ. MONOCEF 1GM IV/BD
4.INJ. METROGYL 100ML IV/TID
5.TAB. DOLO 650 MG TID
6.TAB. SPOROLAC-DS TID
7.INJ. NEOMOL 1GM IV/SOS
8.INJ OPTINEURON 1amp in 100ML NS 9.ORS SACHETS IN 1 LITRE WATER-after each episode of loose stools
DIAGNOSIS: AKI secondary to acute gastroentritis.
TREATMENT:
ON DAY 01:
Tab DOLO 650 mg TID.
Inj. MONOCEF 1gm IV/BD.
Inj. METROGYL 100ml IV/TID.
Tab. SPOROLAC-DS TID.
ON DAY 02:
Inj. PAN 40mg OD.
Inj. ZOFER 4mg IV/sos.
Tab DOLO 650 mg TID.
Inj. MONOCEF 1gm IV/BD.
Inj. METROGYL 100ml IV/TID.
Tab. SPOROLAC-DS TID.
Inj. NEOMOL 1gm IV/sos. {If temp more than 101*f}.
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