Medicine Case

Hello everyone... I am an intern in medicine department and one of the important terms of getting the internship completion is to complete my log book with my daily log of what I learn during the course of my duties. 

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