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Sasira Kasinadhuni
ROLL NO 166
A 80 yr old Male presented with chief complaints of --
Vomitings 3 episodesloose stools 3 episodes
Fever since 1 day
HOPI -
Patient was apparently asymptomatic 2 years back , then he had decreased urine output following which he was taken to near by hospital and was diagnosed with ? renal failure for which he was prescribed some medication and treated accordingly.
Patient c/o 3 episodes of vomitings which were non bilious, non projectile and had food particals as contents,
3 episodes of loose stools, watery in consistency not associated with blood.
H/o fever since yesterday morning, high grade (101 degree F) , they went to local hospital where his GRBS was 500mg/dl , then referred here to KIMS
3 episodes of loose stools, watery in consistency not associated with blood.
H/o fever since yesterday morning, high grade (101 degree F) , they went to local hospital where his GRBS was 500mg/dl , then referred here to KIMS
Past history-
? K/c/o ckd with decreased urine output - has been using a tablet for urine output
N/k/c/o HTN , DM
PERSONAL HISTORY -
married,farmer by occupation with normal appetite and mixed diet , regular bowels, decreased urine output , alcoholic without other addictions
FAMILY HISTORY -
Not significant
VITALS @ ADMISSION
Temperature: 100 degrees F
Pulse Rate: 94/min
RR:17cpm
BP: 80/60mmHg
SpO2: 91% at Room air
GRBS: 193 mg/dl
Pulse Rate: 94/min
RR:17cpm
BP: 80/60mmHg
SpO2: 91% at Room air
GRBS: 193 mg/dl
On examination:
NO Pallor, icterus, clubbing, cyanosis , lymphadenopathy and Edema
CVS: S1S2 +
RS : BAE + NVBS
P/A: Soft , Non tender
CNS: Intact , NAD
NO Pallor, icterus, clubbing, cyanosis , lymphadenopathy and Edema
CVS: S1S2 +
RS : BAE + NVBS
P/A: Soft , Non tender
CNS: Intact , NAD
PROVISIONAL DIAGNOSIS:
ACUTE GASTROENTERITIS 2° to VIRAL
PRE-RENAL ARI (Resolved)
INVESTIGATIONS -
COMPLETE BLOOD PICTURE (CBP)
HAEMOGLOBIN: 13.0gm/dl
TOTAL COUNT: 11,100 cells/cumm
NEUTROPHILS: 86%
LYMPHOCYTES: 11%
EOSINOPHILS : 01%
MONOCYTES: 02%
BASOPHILS:00%
PLATELET COUNT: 1.61lakhs/cu.mm
SMEAR-
Normocytic normochromic with
neutrophilic leukocytosis
LIVER FUNCTION TEST (LFT)
Total Bilurubin : 0.81 mg/dl
Direct Bilurubin: 0.20 mg/dl
SGOT(AST): 27 IU/L
SGPT(ALT) : 25 IU/L
ALKALINE PHOSPHATE: 137 IU/L
TOTAL PROTEINS : 6.6gm/dl
ALBUMIN: 4.2gm/dl
A/G RATIO: 1.82
RFT
UREA: 104mg/dl
CREATININE:2.9mg/dl
URIC ACID:6.4mg/dl
CALCIUM:10.1mg/dl
PHOSPHOROUS:4.0mg/dl
SODIUM:135mEq/L
POTASSIUM:3.6mEq/L
CHLORIDE:90mEq/L
USG
CUE
FBS- 197 mg/dl
HbsAg Rapid - NEGATIVE
HIV RAPID- NON REACTIVE
ANTI HCV ANTIBODIES- NON REACTIVE
TROPONIN I - NEGATIVE
Treatment
on 30/11/21
1)IVF:1 NS,1DNS, 1RL @100ML/HR
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY
Update -
●On 1/12/21
O/E pt conscious
BP - 80/60mmhg
PR - 90bpm
Cvs- S1,S2 +
RS - BAE+
P/A - Soft and non tender
CNS - No FND
1)IVF:1 NS,1DNS, 1RL @100ML/HR
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY
9)INJ CIPROFLOXACIN 500mg/IV/BD
10)Cap AD 100/po/BD
11)ORS satchets - 1 packet in 1 liter of water
Drink 200 ml after each loose stool
2D echo report - 
● On 2/12/21
O/E pt conscious
BP - 100/60mmhg
PR - 90bpm
Cvs- S1,S2 +
RS - BAE+
P/A - Soft and non tender
CNS - No FND
1)IVF:1 NS,1DNS, 1RL @100ML/HR
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY
9)INJ CIPROFLOXACIN 500mg/IV/BD
10)Cap AD 100/po/BD
11)ORS satchets - 1 packet in 1 liter of water
▪︎Advised high potassium diet ▪︎Stool sample microscopy ,fundoscopy and FLC advised
● On 3/12/21
O/E pt conscious
BP - 110/60mmhg
PR - 76bpm
Cvs- S1,S2 +
RS - BAE+
P/A - Soft and non tender
CNS - No FND
1)IVF:1 NS,1DNS, 1RL @100ML/HR
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY
9)INJ CIPROFLOXACIN 500mg/IV/BD
10)Cap AD 100/po/BD
11)ORS satchets - 1 packet in 1 liter of water
Advised Referrals-
Opthalmology-
Gastroenterology-
Fundoscopy- No DR
FLC- absent/normal
●On 4/12/21
O/E pt conscious
BP - 100/70mmhg
PR - 82bpm
Cvs- S1,S2 +
RS - BAE+
P/A - Soft and non tender
CNS - No FND
1)IVF:1 NS,1DNS, 1RL @100ML/HR
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY
9)INJ CIPROFLOXACIN 500mg/IV/BD
10)Cap AD 100/po/BD
11)ORS satchets - 1 packet in 1 liter of water
Stool sample-
fecal leukocyte count - no pus cells seen
No ova/cyst
▪︎Patient advised to be shifted to ward
5/12/2021
O/E pt conscious
PT IS C/C/C
PR: 86bpm
BP: 110/70mmHg
RR- 18cpm
RS: BAE+
CVS: S1S2 +
P/A: soft,non tender
CNS: NO FND
1)IVF DNS&RL @100ml/hr
2)Inj. PAN 40mg /IV/OD
3)Inj. ZOFER 4mg/IV/SOS
4)Inj. METROGYL 500mg/IV/TID
5)Inj. OPTINEURON 1amp in 100ml NS/IV/OD
6)Tab. DOLO 650mg/PO/TID
7)Inj. HAI SIC acc. to sliding scale
8)Inj. CIPROFLOXACIN 500mg BD
9)Cap. REDOTIL 100mg BD
10)ORS sachets in water
100ml/PO/ after every episode of loose stools
11)Inj. HAI s/c
12)BP/PR/Temp charting
13)Tab. SPOROLAC-DS 1 tab po/BD
6/12/2021
O/E
PT IS C/C/C
PR: 84bpm
BP: 110/70mmHg
RR- 18cpm
RS: BAE+
CVS: S1S2 +
P/A: soft,non tender
CNS: NO FND
1)IVF DNS&RL @100ml/hr
2)Inj. PAN 40mg /IV/OD
3)Inj. ZOFER 4mg/IV/SOS
4)Tab. DOLO 650mg/PO/TID
5)Inj. HAI S/C acc. to sliding scale
6)ORS sachets in water
100ml/PO/ after every episode of loose stools
7)BP/PR/Temp charting
8)GRBS Charting 4th hrly
>Patient has been discharged on 6th december
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