A 57 year old female with acute gastroenteritis with prerenal AKI

UNIT 4 ADMISSION: 
A 57 year old female resident of nalgonda , home maker came to casuality with complaints of: 
- Fever since yesterday evening 
-loose stools since yesterday night
 
HOPI: 
Patient was apparently asymptomatic 1 day ago. Then she developed fever which is high grade , intermittent, associated with chills since yesterday evening. Subsided with medication . 
C/O  loose stools 4 to 5 episodes , watery in consistency since yesterday night. 
No c/o pain abdomen, vomitings .
No h/o passage of blood /black stools. 
No h/o bleeding gums , petechiae , red urine, burning micturition . 
No h/o outside food consumption . 

Past history: 

k/c/o DM type 2 since 8 years .( on unknown medication) .
Not k/c/o HTN, TB, Asthma, CAD, CVA 

Personal history : 
She is married .
Diet: mixed 
Appetite: lost
Sleep: Adequate 
Bowel and bladder : regular 
Addictions: no addictions 

O/E: 
Pt is conscious, coherent , oriented to time , place , person 
No pallor, Icterus, cyanosis, clubbing, lymphadenopathy , edema

Temp- 98.6°F 
BP-80/60 mm of hg 
PR- 153/min
 RR- 24/min
Spo2- 95%at RA 
Grbs- 300 mg/dl

Systemic examination: 

CVS: 
s1 s2 present , no murmurs 

RS: 
BAE present, NVBS 

P/A: 
Soft, non tender 
Bowel sounds present

CNS: 
Intact 

Provisional diagnosis: 
Acute gastroenteritis with prerenal AKI

Investigations: 

On 05/09/21:

Hemogram: 
Hb- 11.7 
TLC- 11,200
PLT- 1.88

RFT: 
Blood urea- 48
Sr. Creatinine- 1.8
Na+ : 134
K+ : 4.2
Cl- : 101

LFT: 
TB- 0.87
DB- 0.20
AST- 33
ALT- 19
ALP- 104
Sr. Protein- 5.1
Uric  acid: 5.4 
RBS : 375 

Serology: Negative 

CUE: 

Sugars- nil
Albumin- nil
Rbc- nil
Epithelial cells- 2 to 3
Pus cells- 2 to 3 

Chest xray: 


Xray abdomen: 


Ultrasound:


Ecg:



On 06/08/21: 

Hemogram: 

Hb- 11.7 
TLC- 12300
PLT- 1.62

On 07/08/21: 
Hemogram: 
Hb: 10.1
TLC: 10400
PLT: 1.56

Serum electrolytes: 

Na+ : 139
Cl- : 106
K+: 3.1

On 08/09/21:
Hemogram:
Hb- 10.6
TLC- 9000
PLT- 1.85

SR. ELECTROLYTES:
Na+ : 142 
K+ : 3.1
Cl- : 105

Treatment given:

Day1: 
1. Plenty of oral fluids 
2. IVF - NS, RL, @ 100 ml/ hr 
3. Inj. Pan 40 mg IV OD 
4. Inj . Zofer 4 mg IV BD 
5. Inj. Ceftrioxone 1 gm IV BD (Day 1)
6. Tab pcm 650 mg po sos 
7. Monitor vitals 4th hrly
8. GRBS charting 8th hrly 
9. Strict I/o charting 
10. Tab ultracet 1/2 tab po BD 

Day 2: 
1. Plenty of oral fluids 
2. IVF - NS, RL @100ml/ hr 
3. Inj. Ceftrioxone 1 gm IV BD (day 2)
4. Inj. Pan 40 mg iv od 
5. Inj. Zofer 4 mg iv sos 
6. Non diabetic ors sachets 
7. Tab Redotil 100 mg po BD 
8. Tab pcm 650 mg po sos 
9. Tab ultracet 1/2 tab po BD 
10. Monitor vitals 4th hrly 
11. GRBS charting 6th hrly 
12. Strict I/o charting 
13. Inj . HAI sc

Day 3: 
1. Plenty of oral fluids 
2. IVF - NS, RL @100ml/ hr 
3. Inj. Ceftrioxone 1 gm IV BD (day 3)
4. Inj. Pan 40 mg iv od 
5. Inj. Zofer 4 mg iv BD
6. Non diabetic ors sachets once 
7. Tab Redotil 100 mg po BD 
8. Tab pcm 650 mg po sos 
9. Tab ultracet 1/2 tab po QID
10. Monitor vitals 4th hrly 
11. GRBS charting 6th hrly 
12. Strict I/o charting 
13. Inj HAI sc 
14. Syp potchlor 10 ml po OD 
15. Inj. Metrogyl100 ml Iv tid(Day 1)

Day 4:

1. Oral fluids with ORS sachets (non diabetic ) 
2. IVF - NS , RL @100ml/hr 
3. Inj. Pan 40 mg IV OD 
4. Inj. Zofer 4 mg IV BD 
5. Inj. Metrogyl 100 ml IV TID 
6. Syp. Potchlor 10 ml po BD 
7. Tab PCM 500 mg po sos 
8. GRBS 6th hrly 
9. Inj . HAI sc 




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