59 K. Rithika Vasantha

Greetings to one and all who are currently reading my blog. This is Rithika, a third semester medical student. 
                     
                       This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs. 


Note : This is an ongoing case and will be updated as and when information is provided. This E-log has been made under the guidance of Dr. Siddharth. 


A CASE OF PRE-RENAL AKI SECONDARY TO ACUTE GASTROENTERITIS

Chief complaints :

• Loose stools since 10 days

• Vomitings since 10 days

• Fever since 10 days

History of presenting illness:

• Patient was apparently asymptomatic 10 days back. 

• Then, he developed fever associated with chills and rigor, no diurnal variation, subsiding on taking medication, not associated with nausea / vomiting. 

• Later, he complained of vomitings since 10 days, ( 10 episodes in a day), food particles as content, non-biliary and non blood tinged. 

• Pt also complained of loose stools since 10 days, ( 5 episodes in a day), watery content. 

• Pt also tested positive for TYPHOID 5 days back. 


History of past illness:

• K/C/O alcoholic and smoker. 

• Not a k/c/o DM and HTN

Treatment history:

• Has no treatment history of DM, HTN, asthma, TB, CAD, strokes, cancers, chemoraduation, antibiotics, hormones, blood transfusion. 

Personal history:

• Is married and farmer by occupation. 

• Follows a mixed diet. 

• Appetite - lost

• Micturition - normal

• Bowels - Diarrhoea ( 10-15 episodes /day) 

• No known allergies

• Alcohol - Occasionally

• Tobacco - Smokes 2 packs / day

• No drug addictions

Family history:

• Has no family history of DM, HTN, asthma, TB, CAD, strokes, cancers, heart diseases. 

Menstrual history:

• Age of Menarche - at 12 yrs

• LMP - 46 yrs

Obstetric history :

• Age of marriage - 11 yrs. 


General Examination :

• Pallor - yes
• No cyanosis, icterus
• No lymphadenopathy, clubbing of fingers/toes, no oedema of feet, no malnutrition. 
• Dehydration - mild

Vitals :

• PR - 64 bpm
• RR - 20 cycles/min
• BP - 110/70 mmHg
• Temp. 97.1°C
• GRBS - 88mg/dl

Systemic Examination:

A. Cardiovascular system :

• S1, S2 are heard
• No thrills and no cardiac murmurs

B. Respiratory system:

• No dyspnoea, no wheezing
• Position of trachea - central
• Breath sounds - Vesicular
• No crypts

C. Per Abdominal Examination:

• Shape of abdomen - scaphoid
• Tenderness - present
• No palpable mass , free fluids, bruits
• Liver, spleen not palpable
• Hernial orifices are normal

D. Central Nervous system Examination:

• Pt is conscious
• Speech normal
• No neck stiffness, kerning's 


PROVISIONAL DIAGNOSIS :

        PRE-RENAL AKI SECONDARY TO ACUTE GASTROENTERITIS

Investigations :

On 26.7.21

Ultrasound report :









Treatment :

• IVF - NS, RL, DNS   @75ml/hr
• INJ. PANTOP 40mg/IV/OD
• INJ. ZOFER  4mg/IV/OD
• INJ. METROGYL  100ml / IV / TID
• TAB. SPOROLAC  DS /PO/1 tab
• INJ. MONOCEF  1gm /IV/BD
• ORS SACHET in 1 lit. of water / PD 200ml after passing each stool throughout the day
• TAB. PCM 650 mg/PO/BD
• INJ. NEOMOL 100ml/IV/EDS
          If temperature > 101°C
• TEPID SPONGING
• I/O charting
GRBS charting 6th hourly


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