146 Meghana GM, AKI 2° to acute GE

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 Aug 04, 2021

Venkata Meghana Badam

Roll no -146 , 3rd sem 

 Under the guidance of Dr. Manasa (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 80 yr old female came to casuality on 03/08/2021 with cheif complaints of high grade intermittent fever, chills and rigor since yesterday, 2 episodes of loose stools since yesterday, vomitings - 3 times 

HISTORY OF PRESENTING ILLNESS

      The patient was asymptomatic 2 days ago after which she develop high grade intermittent fever, chills and rigor, 2 episodes of loose stooles, vomitings -3 times 

Bilious /non Blious?? 

No H/O of pain abdomen, cold, cough, burning Micturition and decreased urinary output 

No other complaints 

HISTORY OF PAST ILLNESS 

      Not a k/c/o DM, Asthama, Epilepsy, TB

Known case of HTN

TREATMENT HISTORY 

     4 yrs on tab TELMA-H 40/12.5 for hypertension

PERSONAL HISTORY

 Married

 Occupation?? 

 Normal appetite

 Non vegetarian 

 Mixed diet

 Bowls regular

 Micturition normal

 No known allergies

 Alcohol - occasional

FAMILY HISTORY

   No H/O of similar complaints in the family

GENERAL EXAMINATIONS

    No -pallor/Icterus/Cyanosis/Clubbing/Lymphadenopathy/Edema/Malnutrition

Dehydration - yes

Temperature -103 C/F

Pulse rate - 96 /min

Bp - 130/60 mm/hg

Spo2 - 96 %

GRBS - 126 mg%

SYSTEMIC EXAMINATION

CVS:  

No Thrills

Cardiac Sounds - S1, S2 +

No cardiac murmurs

RESPIRATORY SYSTEM: 

Dyspnoea - No

No Wheezing

Position of Trachea - Central

Vesicular sounds 

ABDOMEN:

Shape - Obese

No tenderness, palpable mass, No fluid, No bruits, 

Bowel sounds- present

Hernial Orifices - Normal

Liver Spleen - Not palpable

Genitals speculum examination, PV examination, P/R examination - Normal

CNS:

Level of consciousness - conscious

Speech - Normal

No signs of meningeal irritation

Cranial nerves - Normal

No motor or sensory deficit

Glassgow scale -15/15

GAIT, MUSCULO SKELETAL SYSTEM, SKIN, EXAMINATION OF BREAST, ENT, TEETH AND ORAL CAVITY, HEAD AND NECK - NORMAL 

INVESTIGATIONS:

















PROVISIONAL DIAGNOSIS 

 AKI 2° To Acute GE

Known case of HTN

 AKI generally is associated with pedal edema pitting type, sob, decreased albumin levels, abnormal micturition and abdominal pain which are not seen in this patient 

I Don't know how she is diagnosed with AKI, might suffering from CKD

TREATMENT


Iv fluids NS, RL continues @100 ml/hr

Inj. PAN 40mg Iv/OD 

                            1-x-x

Inj. MONOCEF 1gm Iv/BD

                             1-x-1

Inj. METROGYL  100 ml Iv/TID

                             1-1-1

Tab dolo 650 mg 

Tab sporolac -DS TID 

                           1-1-1

Inj. NEOMOL 1gm Iv/sos (if temp >101°F) 



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