40 f with vomiting diarrhoea anuria

-
CHIEF COMPLAINTS

40 year old female brought to casualty with chief complaints of

1) loose motions since yesterday

2) vomitings since yesterday

3) anuria since yesterday

HOPI

pt was apparently asymptomatic since yesterday.she attended a family gathering and ate mutton .


  she had vomitings and loose motions since yesterday mrng 4:00am.


 vomitings 


about 10 to 15 episode 


watery in consistency 


non foul smelling , non bilious, non projectile, 


not a blood stained,


not associated with nausea, fever, not associated with abdominal pain


loose motions since 4.00 am in the mrng


 about 10 to 15 episodes


 watery in consistency, 


not foul smelling and not blood stained .


no blood in stools.


not associated with abdominal pain, fever

Complaints of anuria since yesterday 8:00am 


 

for which admitted at nalgonda hospital at 10:00 am. and discharged at 9:00 pm and got relieved of vomitings and loose motions and was put urine bag and referred here

DAILY ROUTINE

wakes up at 6 :00 am and does her routine work and prepares food and goes to work at 9: 00am and returns home at 5:00 pm and cooks food and goes to bed at 9:00pm


PAST HISTORY:-

not a known case of DM HTN ASTHMA EPILEPSY TB


PERSONAL HISTORY

DIET:- Mixed

APPETITE:- Decreased

SLEEP:-inadequate

BOWEL AND BLADDER MOVEMENTS:-loose stools and anuria

ADDICTIONS:-consumes toddy occasionally ( during festivals)


FAMILY HISTORY

not significant


GENERAL EXAMINATION

pt is conscious coherent cooperative well oriented to time place person


pallor- mild

icterus- absent

clubbing- absent

cyanosis- absent

edema - absent

lymphadenopathy- absent


VITALS:-( at the time of admission)

BP :-110/70mm hg

PR:-82 bpm

GRBS:-119 mg/dl

TEMP:-:-98.6

SYSTEMIC EXAMINATION

CVS- S1 , S2 heard , no added murmurs

RS - BAE present, vesiculat breath sounds heard

CNS - Intact

INSPECTION inspection- shape - schapoid and symmetrical

umbilicus- inverted and central in position

no visible scars, dilated veins

Palpltion- no local riss of temperature, tenderness in umbilical , rt and lt lumbar, hypogastrium , rt and lt illeac are

sleep and liver not palpable

no palpable mass

Bowel sounds-heard


DIAGNOSIS:- 

Acute gastroenteritis with ? AKI



INVESTIGATIONS

Treatment

28/08/2022
1) 2 U NS bolus if no urine output inj.lasix 10 mg IV stat---------> NS , RL @ 100 ml/ hr
2) T.Loperamide 4mg po stat
3) Inj.Pantop 40 mg IV OD
4) Inj.Zofer 4mg IV / sos
5) Inj . Monocef 1gm  IV BD
6) Inj. Metrogyl 100ml IV TID
7) ORS sachets in 1 Litre water 200 ml after each stool
8) Tab Splrolac 2 tabs PO BD
                 
29/08/2022

1.IV fluids NS RL @100 ml /hr
2.INJ.Pan 40mg IV/ OD
3.INJ.zofer 4mg/IV/SOS
4.INJ.Monocef 1gm/IV/BD
5.INJ. Metrogyl 100ml IV/TID
6.ORS sachets 1 in 1 litre of water 200ml after each stool.
7.TAB.DOLO 650PO/SOS
8.T.sporolac 2 tabs /PO/OD
9.INJ.Neomol 1gm /IV/SOS

  30/ 08/ 2022

1.IV fluids NS RL @100 ml /hr
2.INJ.Pan 40mg IV/ OD
3.INJ.zofer 4mg/IV/SOS
4.INJ.Monocef 1gm/IV/BD
5.INJ. Metrogyl 100ml IV/TID
6.ORS sachets 1 in 1 litre of water 200ml after each stool.
7.TAB.DOLO 650PO/SOS
8.T.sporolac 2 tabs /PO/OD
9.INJ.Neomol 1gm /IV/SOS

31/08/2022

1) IV Fluids NS , RL @ 100ml/h
2) INJ ZOFER  40 mg IV /OD
3) INJ PAN 40 mg IV /sos
4) INJ MONOCEF 1 gm IV/BD
5) INJ. METROGYL 100ml IV / TID
6) ORS sachets in 1 Lit of water 200 ml after each  stool
7) TAB PCM 650 mg PO/sos

1/09/2022

1.TAB.Pan 40mg PO OD
2.TAB.zofer 4mg PO SOS
3.TAB PCM 650 PO SOS
4.TAB MVT PO OD




Comments

Post a Comment

Popular posts from this blog

RIGHT HEART FAILURE SECONDARY TO COPD

-
Image
  under the guidance of Dr. Rishik (Intern) This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission. 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 a diagnosis and treatment plan. CASE SCENARIO: A 52yr old patient came to the ward on 29 June 2021 with chief complaints of  right lower limb swelling, intermittent fever (alive and well), shortness of breath  since 3days, and  burning micturition  for 15 days. HISTORY OF PRESENTING ILLNESS The patient was asymptomatic 5days ago, after which he developed right lower limb swelling up to the knee. No H/O trauma, thorn prick, nausea, vomiting c/o a small wound, watery discharge since 2 days Fever- 5days intermittent, low grade, a/w chill A light rise in temp sob on exertion -5days a/w cough- 1
Read more

30f with osteomalacia??

-
Image
A 30yr Old Female with ? Osteomalacia 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 is welcome I've 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 a diagnosis and treatment plan CASE A 30yr old female, Daily wage Labourer by occupation came to OPD with cheif complaints of Pain in B/L Lower limbs since 2 years.  Patient wa
Read more

OSCE QUESTIONS

-
1) Having history of BPH and DM 2,if he develops renal failure what will be the cause. Pre renal or post renal?  2)How to divide the insulin dosage?  3) How adipokines causes insulin deficiency?  4) How furosemide causes tetany and muscle cramps ?  5) How to furosemide causes weakness ?  6) In case of liver cirrhosis and heart failure , how to differentiate the edema is caused due to liver failure or heart failure ?  7) How do anemia cause hypopitutarism?  8) Why in IVC obstruction there are dilated veins ?? And why their fillings occurs from bottom to top ?  9) What are the causes of vertebro basillar insufficiency?  10) What is the efficacy of vertin ?  11) What is the effectiveness of promethazine / ondencetron / vertin in cases of relieveing vestibular vertigo ?
Read more