CASE PRESENTATION:
A 65 year old female who is a housewife came to the casuality with complaints of Loose Stools since 2 days and Fever since 2 days.
HOPI:
The patient was apparently asymptomatic 2 days back then she developed fever which was insidious in onset, low grade, intermittent type, not associated with chills and rigors.
associated with vomitings 1 episode food as content, non-bilious.
she also presented with loose stools since 2 days. 10episodes/day, watery, non-mucoid, non-blood stained, small volume, not associated with pain abdomen.
patient also complains of decreased urine output since 2 days,not associated with burning micturition
history of facial puffiness since 1 day.
no history of cough,cold, SOB,pedal edema, chest pain.
no history of orthopnea, PND, LOC,seizures.
PAST HISTORY:
patient is a K/C/O Right upper limb and lower limb weakness with slurring of speech since october 2019 (Hemiparesis secondary to infarct in the Right parietal region)and is on regular anti-platelets.
k/c/o HTN since 8 months and is on regular medication (T.olmesartan+T.hydrochlorthiazide)
not a k/c/o TB, asthma, CAD, seizures
no history of previous blood transfusions and surgery.
FAMILY HISTORY:
no significant family history.
PERSONAL HISTORY:
diet-mixed
appetite-normal
sleep-adequate
B&B-regular
addictions-none
GENERAL EXAMINATION:
Patient was conscious, coherent,cooperative
moderately built and nourished
Pallor-present,no signs of icterus,clubbing,cyanosis, lymphadenopathy, edema.
vitals-
PR=67bpm
RR=20cpm
GRBS=147mg%
spO2=96%
BP=50/20mmHg***(at the time of presentation)
[with this presentation she was immediately resuscitated with IV Fluids, NS at 20ml/kg bolus, later the on examination it increased to 80/50mmHg]
SYSTEMIC EXAMINATION:
1.RESPIRATORY SYSTEM: B/L air entry present, normal vesicular breath sounds heard,Not added sounds
2.CVS: S1 S2 heard. no murmurs
3.PER ABDOMEN: soft, non tender. Bowel sounds present.
4.CNS:
higher mental functions: intact with slight slurring of speech
cranial nerves : intact
motor sysyem:
RIGHT LEFT
Nutrition normal normal
Tone UL normal normal
LL normal normal
Power : UL 4/5 4/5
LL 4/5 4/5
reflexes:
1.biceps: +++ +++
2.triceps ++ +++
3.supinator +++ +++
4.knee +++ +++
5.ankle ++ ++
plantar flexor flexor
SENSORY SYSTEM:
pain=normal
touch=normal
temperature=normal
proprioception=normal
CEREBELLUM:
intact
MENINGEAL INVOLVEMENT:
None
with the following clinical findings following investigations were sent:
1.CBP
2.ABG
3.LFT
4.RFT
5.RBS
6.Ultrasound abdomen.
7.PERIPHERAL SMEAR
8.RETICULOCYTE COUNT
9.BLOOD GROUPING& Rh typing
10.ECG
ABG After correction.
With the above findings,
DIAGNOSIS: AKI secondary to ACUTE GE (intrinsic AKI)
With severe metabolic acidosis
HYPOVOLEMIC SHOCK
with Anemia
with k/c/o HTN & old CVA(Right UL &LL Weakness)
TREATMENT:
1.IVF (0.9%NS) @Urine Output +30ml/hr
2.Plenty of oral fluids 2 L/day
3.Soft oral diet.
4.ORS sachets in 1 lit of water.Drink 200ml after each loose stool.
5. Inj. PAN 40mg/iv/od
6.Inj. ZOFER 4mg/iv/sos
7.T.SPOROLAC tid
8.T. ECOSPIRIN AV 75/20mg PO
9.BP/PR/spO2 charting 2hrly
10.Strict I/O charting
11.GRBS 6th hrly.
12.Inj. Lasix 20mg/iv/bd
13.T. Nodosis 500mg/po/bd
14.Blood transfusion