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 

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