Gastroenteritis with Acute Kidney Injury
20/07/ 2022
A This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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 diagnosis and treatment plan
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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 diagnosis and treatment plan
A 54yr old woman ,r/o miryalaguda,farmer by occupation ,came to OPD with chief complaints-
Umbilicus -central
Complete blood picture
Treatment
Serum creatinine
Complete blood picture
-loose stools and vomitings since 1week
HOPI
Patient was apparently asymptomatic 7days back, then she had 4-5episodes of loose stools per day which is non foul smelling, non blood tinged and green in colour.
Vomitings which is non projectile,non biliary, food particle contents are present, and every episode after food intake and not associated with pain abdomen.
Associated complaints-B/L knee pain since 10yrs. On NSAIDS , intermittently.
B/L pedal edema since 4days which is pitting type -subsided now
No history of fever,nausea.
DAILY ROUTINE
The patient’s attender remarked that the patient wakes up at 6AM and sweeps the floor after freshing up. She has tea&breakfast at 9:00 AM and helps in minor household chores.She has lunch at 1:00 PM and sleeps for sometime in the afternoon and after she wakes up watches TV and has dinner at 8:00 PM and sleep at 9:30 PM.
PAST HISTORY
No similar complaints in the past.
No H/o Diabetes,Hypertension,Asthma and Thyroid disorders.
H/o decrease hearing sinced 28-30yrs.
H/o hysterctomy 15yrs ago.
TREATMENT HISTORY
NSAIDS -intermittently
PERSONAL HISTORY
Diet -Mixed
Appetite-good
Bowel and bladder -regular
Sleep-adequate
Addictions- Toddy since 10yrs occasionally.
FAMILY HISTORY
No significant family history.
MENSTRUAL HISTORY
Menarche-12yrs.
Cycle-used to be regular
GENERAL EXAMINATION
Patient is conscious ,coherent and cooperative. Well oriented to time place and person
Moderately built and nourished.
Pallor absent
Icterus absent
Clubbing absent
Cyanosis absent
Lymphadenopathy absent
Edema -present
Denydration-present(moderate)
Vitals
Temp-afebrile
PR-94/min
RR-18 cycles/min
BP-90/60mm Hg
Spo2 -94%
GRBS-106mg%
SYSTEMIC EXAMINATION
Abdomen examination
Inspection-
Abdomen is scaphoid
No sinus/scars
No visible peristalsis
Palpation-
No local raise of temperature
Tenderness -absent
Liver -palpable
Spleen not palpable
Percussion
No shifting dullness
No fluid thrill
Auscultation
Bowel sounds heard
Respiratory Examination
Chest bilaterally symmetrical, all quadrants
moves equally with respiration
Trachea central, chest expansion normal
B/l equal air entry
no added sound
CVS examination:
S1 S2, No murmur
CNS: No focal neurological deficits
Provisional Diagnosis- Acute gastroenteritis with pre renal acute kidney injury with Hbs -Antigen positive
INVETIGATIONS
Haemogram,ECG, chest X-ray,RFT,LFT,USG
18/07/22
LFT
19/07/22
Blood grouping
Blood sugar
Inj.pantop 40mg/IL/oD
Inj.Zofer 4mg
TAB Sporolac
ORS sachet
Inj optineurin
Follow up
21/07/22
Serum urea
Complete blood picture
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