50 year old female with chief complaints of loose stools, vomitings
A 50 year old female came to the medicine opd with c/o loose stools since 4 days and vomitings since 3 days
Hopi : patient was apparently normal 4 days back then she developed fever which is of high grade , intermittent associated with chills and rigor relieved by medication . Subsided now .
C/o loose stools since 4 days
Watery, non foul smelling, non mucoid , not blood stained 4 to 5 episodes per day
and c/o vomitings 3 days back watery, non projectile , non bilious with food particles as content 4 to 5 episodes subsided now
C/o facial puffiness and swelling of upper limb
No H/o cough, cold , decreased urine output , pedal edema,SOB .
No H/o chest pain , palpitations ,orthopnea , PND .
C/0 loss of appetite since 3 days
No H/o constipation.
Past history: K/C/O DM type 2 since 5 years on tab GLIMI M2 PO/OD HTN since 1 year on tab TELMA 40 Mg PO/OD
N/K/C/O TB, Asthma , Epilepsy , CVA, CAD, Thyroid disorders.
Personal history:-
Diet - Mixed
Appetite - decreased
Bowel and bladder - regular
Sleep - adequate
addictions occasionally alcoholic
Stopped 8 months ago
Stopped smoking chutta 8 months back .
No H/o food and drug allergies
Family history:-
Not significant
General examination:-
Patient Patient is conscious, coherent, cooperative ,moderately built and nourished
Pallor present , puffiness of face present
No signs of icterus, cyanosis, clubbing, generalised lymphadenopathy
Oedema
Vitals at the time of admission
Temp- afebrile
BP-140/80mmHg
PR- 86 bpm
RR - 18 cpm
SpO2- 99 % at RA
GRBS - 50 mg/dl .......>. After giving 25 D 110 mg/dl
Systemic examination :
CVS- S1;S2 + , no murmurs
RS- BAE+ NVBS heard
P/A- Soft non tender, no organomegaly
CNS :- Patient is arousable , no focal and neurological deficits
Investigations on 3/11/23
Provisional diagnosis: AKI on ? CKD secondary to acute Gastro enteritis with OHA Induced hypoglycemia with k/c/o DM Type 2 since 5 years and HTN since 1 year with 2 sessions of hemodialysis done on 4/11/23 and 6/11/23. With 1 prbc transfusion on 6/11/23
Daily routine of patient :
6:00am -wakes up
6:00am -7:00am : fresh up
7:00am -9:00am : house work (dish washing , laundry etc..)
9:00am : Breakfast ( Rice and dal )
10:00am -12:00pm : house work
12:00pm-1:00pm : walking
1:00pm : Lunch (Rice with curry and curd )
2:00pm-4:00pm : walking ,sleep
5:00pm -6:00pm : Talking with neighbors ,watch tv
7:00pm : Dinner ( Rice or Roti with curry or dal )
7:00pm -9:00pm : watches tv
9:30pm : sleep
Treatment given in the hospital
IV fluids DNS @ 100 ML/HR
IV FLUIDS 25% D @ 15 ML/HR
INJ CEFTRIAXONE 1g IV /BD
INJ METROGYL 500 MG IV/TID
INJ LASIX 20 MG IV/BD
INJ ZOFER 4 MG /IV/SOS
TAB . CLINIDIPINE 1O MG PO/OD
TAB. SPOROLAC DS PO/TID
6/11/23
S: no fever spikes , vomitings and loose stools subsided
O : pt is conscious, coherent, cooperative
Bp : 110/70 mm hg
Pr : 78 bpm
Rs : BAE + NVBS + ,NO added sounds
Cvs : s 1, s2 + , no murmurs
P/A : soft , NT
CNS : NFND
A : AKI on CKD Secondary to acute gastroenteritis with OHA INDUCED HYPOGLYCEMIA ( resolved)
K/c/o DM T2 and HTN
with 2 sessions of hemodialysis done on 4/11/23 and 6/11/23 with 1 prbc transfusion done on 6/11/23
P:
INJ CEFTRIAXONE 1g IV/ BD
INJ METROGYL 500 mg IV /TID
INJ ZOFER 4 mg IV /SOS
Tab LASIX 40 Mg PO /BD
Tab CLINIDIPINE 10 mg PO/OD
7/11/23
S: no fever spikes , vomitings and loose stools subsided
O : pt is conscious, coherent, cooperative
Bp : 110/70 mm hg
Pr : 88 bpm
Rs : BAE + NVBS + ,NO added sounds
Cvs : s 1, s2 + , no murmurs
P/A : soft , NT
CNS : NFND
I/o : 900/1400
A : AKI on CKD Secondary to acute gastroenteritis with OHA INDUCED HYPOGLYCEMIA ( resolved)
K/c/o DM T2 and HTN
with 2 sessions of hemodialysis done on 4/11/23 and 6/11/23 with 1 prbc transfusion done on 6/11/23
P:
Tab ciprofloxacin 500 mg BD
TAB .ECOSPRIN AV 75/10 OD
Tab LASIX 40 Mg PO /BD
Tab CLINIDIPINE 10 mg PO/OD
SYP POTCHLOR 10 ML IN 1 GLASS WATER TID
SYP ARISTOZYME 10 ML BD
SYP CREMAFFIN PLUS 15 ML BD
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