Sudheer kumar 66

40 year female with vomitings, loose motions and anuria

- August 27, 2022

 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 patients clinical problems with collective current based inputs.

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

29/08/2022

30/08/2022

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