48yr old female with loose. stools & vomitings since 3 days.

-

CBBLE UDHC Similar case



This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan

48 year old female daily wage labourer by occupation came with the complaints of loose stools and vomiting since 3 days and no urine output since yesterday afternoon .

HOPI: 
patient came with the complaints of loose stools 5 -6 episodes/ day watering consistency,  non mucoid , non bloodstained since 3 days. 
Complaints of vomitings 4-5 episodes bilious , non projectile,  food as content
H/o mutton consumption 4 days ago. 
No h/o fever , burning, micturition, cough, cold.  Sob





PAST HISTORY : N/k/c/o of Dm, HTN, CAD , TB, BA, Epilepsy. 
No previous hospital admissions. 


O/E
 pt is conscious , coherent, coperative 

Temp : 98.6 f
PR : 82 bpm 
RR : 24 cpm.
BP : 140/80 mm hg
Spo2 : 97 %@ RA
grbs : 107 mg/dl 

Pallor +
No icterus, cyanosis, edema , lymphadenopathy

CVS : s1 s2 + 
RS : BAE + NVBS
CNS : NAD
P/A : soft &  non tender 

INVESTIGATIONS : 
On 17/3/22

HB : 9.2
TLC: 13,100
PCV:28.3
PLT:2.78
N/L/M/E/B: 86/8/2/4/0

UREA: 112
SR.CR: 5.4
Na+:138
K+: 3.3
Cl+: 101

PH : 7.08
Pco2:15.3
Po2: 113
Hco3: 7.1

decreased   skin turgor 







DIAGNOSIS : Acute Gastro Enteritis with AKI 


TREATMENT :  

On 17 /3/22 
1)IVF NS, RL,  DNS @ 150 ml / hr 
2)INJ. MONOCEF 1gm / i.v/ BD
3) INJ. METROGYL 100
ml /i.v/TID
4) inj. LASIX 20 mg i.v BD 

5) Syp.potchor 10ml in 1glass water BD
6) Plenty of oral fluids.

Passed urine ( 75 ml )  at 11:30 pm on 17/3/22. 

18/3/22
CST

 19/3/22
CST 
added inj. Kcl 1amp in 500 ml NS I.V over 5hrs 
Tab. Sporolac DS TID 

Comments

Post a Comment

Popular posts from this blog

42yr old female suffering with multiple ailments

-
I have been given this case to solve and interpret to enhace my competency and as an attempt to understand the topic of  "patient clinical data analysis" You can find the entire clinical problem of the patient in this link  https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html   Priority of her complains according to my analysis 1) Severe headache associated with visual aura. loss of function & numbness  on left side  Falling to left side  Vertigo  csf rhinorrhea from left nostril  Aggravated by :stress,mensus, birth control pills  Headache was relieved by taking medication (triptans) Diagnosis : Most probably hemiplegic migraine Differential diagnosis may be  Space occupying lesion on right side.                                        I ncreased ICT  Secondary headache syndrome Cerebral vasculitis ( presents as headache & neurological deficit )   HEMIPLEGIC MIGRAINE       What Causes Them? So far, researchers have found four genes
Read more

pain abdomen secondary to uncontrolled sugars with DKA with ? pancreatitis with AKI on CKD. (CKD secondary to metabolic acidosis ) with HFPEF( EF- 58%) with metabolic acidosis secondary to DKA & CKD with H/o DM-2 , hypothyroidism , CKD

-
Image
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan 43 year female came with complaints of pain abdomen & vomitings since 1 day HOPI : Patient was apparently asymptomatic 6 yrs back, then had anasarca , went to hospital in hyderabad &
Read more

26 yr old male with fever

-
Image
CBBLE UDHC Similar case This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan 26 yr male mechanic by occupation came with c/o fever , since 5 days which is high grade , associated with chills , intermittent, relieved with medication .  No h/o v
Read more