Case history -6

 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. 

  A  50 year old female has come to casualty with chief complaints of pain in abdomen and vomiting for 2 hours and also complaints of loose stools for 2 hours.

HISTORY OF PRESENT ILLNESS:

Patient was apparently well and asymptomatic 2 hours back and  then developed pain in abdomen mainly more in right iliac fossa.Pain was gradually progressive with sudden onset.

Patient complaint of 2 episodes of vomiting which is non bolus, non blood tinted.

Patient complaint of diabetic foot.


HISTORY OF PAST ILLNESS:
Patient was undergoes to dialysis 15 days back and patient complaints of diabeties mellitus and hypertension since 10 years.

PERSONAL HISTORY:
Diet: normal.
Appitite : mixed.
Bowel and bladder movement: normal.
Micturition: normal.
No addictions.
 
FAMILY HISTORY:
No family history such as diabetes, hypertension, heart diseases , cancer.

TREATMENT HISTORY:
 Patient uses medications for diabetics and hypertension .
No history of blood transfusion, asthma, Tuberculosis, chemotherapy, radiation.
Patient as not undergone to any surgery.

GENERAL PHYSICAL EXAMINATION;

Patient consent was taken and examined in a well lit room.
 No generalised lymphadenopathy.
No icterus, clubbing, cyanosis, pallor, pedal edema or dehydration.
 
VITALS: 
Temperature:98.5 degree Fahrenheit.
Pulse rate:99/ minutes.
Respiratory rate:18 / minutes.
Blood pressure: 140/80 mm Hg.
SpO2 at room air : 99%.
GRBS: 323mg%.


SYSTEMIC EXAMINATION: 

Cardiovascular system:

No thrills and cardiac mummers .

S1 and S2 are heard .

Respiratory system:

No wheezing and dyspnoea.

Positioning of trachea is central and breath sounds are vesicular.

Abdomen:

Shape of abdomen: obsese.

No tenderness and no palpable mass is present.

No free fluid and bruits and liver and spleen are not palpable and bowel sounds are not heard .

Central nervous system:

Patient is conscious and speech is normal.No signs of meningeal irritation such as neck stiffness and kerning's sign.

Cerebral signs such as finger - nose in coordination and knee - heal incoordination are not present .

PROVISIONAL DIAGNOSIS:

Pre renal AKI on CKD ( secondary to acute  gastroenteritis) with Diabetes Mellitus since 10 years.

INVESTIGATION:


ULTRASOUND REPORT:


HEMOGRAM:

The Haemoglobin level is decreased and total count is increased.
The packed cell volume has been decreased and mean copsular as also been decreased.
The lymphocytes has been decreased.

BLOOD UREA:


SERUM CREATININE:


SERUM ELECTROLYTES;


 TREATMENT : 

Day 1:

Intravenous fluids -RL ,NS at 50 ml/hr

Inj. Metrogyl 500mg/IV/ TID

Inj. Tramadol 1amp in 100 amp NS/IV/SOS

Inj. Hai Pre meal S/C TID

tab .Zofer 4mg PO/SOS

Inj. Vancomycin 1G in 100 ml /IV/slowly through central line over 1 hour .

ORB sacket in 1 litre of water to drink throughout the day after each stool.

Day 2: 

Intravenous fluids -RL ,NS at 50 ml/hr

Inj. Metrogyl 500mg/IV/ TID

Inj. Tramadol 1amp in 100 amp NS/IV/SOS

Inj. Hai Pre meal S/C TID

tab .Zofer 4mg PO/SOS

Inj. Vancomycin 1G in 100 ml /IV/slowly through central line over 1 hour .

ORB sacket in 1 litre of water to drink throughout the day after each stool

Daily dressing for Diabetic foot .

GRBS charting 8th hourly.

DAY 3 : 

Intravenous fluids -RL ,NS at 50 ml/hr

Inj. Metrogyl 500mg/IV/ TID

Inj. Tramadol 1amp in 100 amp NS/IV/SOS

Inj. Hai Pre meal S/C TID

tab .Zofer 4mg PO/SOS

Daily dressing for Diabetic foot .

DAY 4:

Intravenous fluids -RL ,NS at 50 ml/hr

Inj. Metrogyl 500mg/IV/ TID

Inj. Tramadol 1amp in 100 amp NS/IV/SOS

Inj. Hai Pre meal S/C TID

tab .Zofer 4mg PO/SOS.

Dressing for diabetic foot.

Advice of discharge:

Tab 40 mg /PO/OD for 1 week

Tab MVT PO / OD for one week 

Tab.zofer 4mg PO/SOS for one week

Inj. Mixtard S/C pre-meal

Follow up :

Review to medicine OP after one week/SOS.






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