45 yr old with AKI secondary to acute GE

E-LOGS GENERAL MEDICINE


 
Roll no 04 
Hi, i am lasya, 5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. 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 best evidence based inputs. Hope this will be informative!


A 45yr old female patient came to casualty with chief complaints of nausea and  vomitings since 15 days.

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 4 yrs back , when she developed burning micturition , pedal oedema , rt. Loin pain for which she visited local hospital and was diagnosed with rt.renal calculi (2.3cms) associated with pyelonephritis , they are then referred to nims where she underwent nephrectomy in 2018.
Since then she had complaints.

She came to casualty with complaints of nausea and vomiting associated with epigastric discomfort .
4 to 5 episodes of vomiting 
Small quantity food particles as contents 
No blood in vomiting 

PAST HISTORY: 
Rt .nephrectomy in 2018
No history of DM HTN CAD TB asthma ..

PERSONAL HISTORY:
Diet - mixed
Appetite - lost
Addictions - no history
Sleep - normal
Bowel and bladder movements - normal 

FAMILY HISTORY:
NOT SIGNIFICANT

GENERAL EXAMINATION:
Oedema of feet - seen 
Pallor - not seen
Icterus -not seen
Cyanosis-not seen
Clubbing -not seen
Lymphadenopathy -not seen




VITALS :
TEMPERATURE: afebrile
Pulse rate -82bpm
Respiratory rate - 16/min
BP - 130/80
SpO2 - 98%

SYSTEMIC EXAMINATION:
CVS : 
S1 S2 heard
No thrills and murmurs

RESPIRATORY SYSTEM:
Position of trachea - central 
Dyspnea and wheeze - absent 
Breath sounds - vesicular

ABDOMEN:
Soft , non tender 

CNS :
NFND 

PROVISIONAL DIAGNOSIS :
AKI secondary to acute gastroenteritis 


INVESTIGATIONS :
TREATMENT:
1) inj.PAN 40mg IV/OD
2)inj.METROGYL 500mg IV /TID
3)inj. ZOFER 4mg IV/SOS
4)inj.OPTINEURON 1amp in 100ml NS
5)tab DOLO 650mg PO/SOS
6)tab MVT PO/BD 
7)LASIX 

Comments

Post a Comment

Popular posts from this blog

65yr old with ascites

Image
E-LOGS GENERAL MEDICINE   Roll no 04  Hi, i am lasya, 5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. 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 best evidence based inputs. Hope this will be informative! * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required. A 65 yr old female patient came to OPD with complaints of shortness of breath since 15 days and abdominal swelling since 13 days . HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 20 days back when she developed high grade fever and decreased urine output which lasted for 5 days after taking medicine. She was asymptomatic for 4 days . Then
Read more

45 yr old with paraparesis

Image
E-LOGS GENERAL MEDICINE   Roll no 04  Hi, i am lasya, 5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. 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 best evidence based inputs. Hope this will be informative! * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required. A 45yr old female patient came to casualty with complaints of * Abdominal tenderness , distension and discomfort since 4 days  * Decreased urine output since 4 days  HISTORY OF PRESENT ILLNESS: She was apparently asymptomatic 1 year ago when she developed fever , followed by pain in the back . She visited some hospital where they were told to have spinal
Read more

70 yr old with CRF

Image
             E-LOGS GENERAL MEDICINE Hi, i am lasya, 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. 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 best evidence based inputs. Hope this will be informative! * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required. A 70 year old male came to the casuality with pedal edema & vomiting. CHIEF COMPLAINTS: *c/o pedal edema since 1month  which is progressive pitting type bilateral associated with facial puffiness and vomiting. * Shortness of breath (-) * Oliguria (-) * Abdominal distension (-)   * No other complaints. HISTORY OF PRESENT  ILLNESS: * History of b/l pedal
Read more