60 Y female with multiple episodes of loose stools associated with vomitings since 3 days and decreased intake of food and fluids since 2 days


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 available 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-centered online learning portfolio and your valuable inputs on the comments


 60 year old female patient resident of miryalguda,previously a tailor, now a homemaker.patient stays alone,but near her elder son.

Patient came with complaints of fever-1 episode 5 days back.

Loose stools since 3 days, multiple episodes,resolved now,associated with vomitings,containing food particles,non bilious, no hemoptysis. Decreased  oral intake of food and fluids since 2 days

No dark colored stools,no pain abdomen,

Since yesterday all her symptoms aggravated. Patient was unable to get up from bed,and found soiled her clothes,then patients son took her to hospital and got admitted in local hospital. They referred her in view of renal failure and thrombocytopenia.(she was managed with IV fluid and noradrenaline for hypotension 50/30. Patient also complained of decreased urine output and shortness of breath since yesterday.

No history of pedal edema,chest pain, burning micturition.

Past history:patient is known case of hypertension since 15 years. No history of DM, aasthma,epilepsy,CAD,CVA.

H/O myalgias in the past for which she used to take medications prescribed by RMP for short term pain relief

Personal history:

Diet: mixed

Appetite: decreased 

Bowel and bladder: regular

Micturition: normal

Addictions: none

General examination: patient is conscious,coherent,cooperative.

Well built and truncal obesity is present



 Patient is severely dehydrated

No pallor,icterus,cyanosis, clubbing,kylonechia,lymphadenopathy,edema..

Vitals:

BP: 90/60

Pulse:96/min

Respiratory rate:38/min

Spo2:91% at RA

GRBS:106 mg/dl 

Temperature: afebrile



Systemic examination:

CVS:S1 S2 +

RS:Dyspnea is present,decreased breath sounds in left IMA, left IAA with wheeze

Abdomen: shape- obese

no tenderness,no palpable masses

CNS: no abnormalities 

Diagnosis: severe dehydration- hypovolemic shock

Acute gastroenteritis with sepsis

AKI on CKD with anemia,thrombocytopenia,hypoalbuminaemia.

K/C/O HTN

Treatment on day 1 at admission:

Inj.ceftriaxone 1gm/IV/BD after sending cultures

Inj.metrogyl-100ml/IV/TID

Inj.Pantop-40mg /IV/OD

Inj.noradrenaline-2amp in 50ml NS@ 4ml/hour increase according to BP MAP >65mm hg

O2 inhalation-6lit/min

IVF DNS ,NS  @100ml/HR continuous infusion

Inj.bicarbonate-50ml/slow IV

Tab.Nodosis-500mg/PO/BD

Tab.shelcal-500mg/PO/BD

Tab.Alpha D3-0.2mg/PO/OD

B.protein powder-2 scoops in 100ml of milk/PO/TID

Watch for bleeding manifestations 

PR/BP/SPO2 hourly monitoring 

Strict I/O Charting 

GRBS monitoring 6th Hourly

Treatment on Day 2:

Plenty of oral fluids

IVF-NS @100ml/HR continuous,1 DNS @75ml/hr

Inj.Noradrenaline 2 ampules in 40 ml NS titrating infusion according to the BP to maintain MAP> 65 mm hg

Inj.Pantop 40mg/IV/OD

TAB.Shelcal 500mg/PO/BD

TAB.Nodosis 550 mg/PO/BD

Inj.metrogyl 100ml/IV/TID

CAP. Alpha D3 0.25 mcg/PO/OD

Protein powder 2 scoops in 1 glass milk/PO/TID

Inj.Lasix 40 mg/IV/TID if SBP> 110mm hg

Strict I/O charting

PR/BP/SP02 charting hourly

GRBS monitoring 8th hourly

SYP.Grillinctus 10ml/PO/BD

 TAB.Ultracet PO/BD

Treatment on day 3:

Plenty of oral fluids

IVF-NS @100ml

Inj.metrogyl 100ml/IV/TID

Tab.Azithromycin 500 mg/PO/OD

Inj.Noradrenaline 2 ampules in 40 ml NS titrating infusion according to the BP to maintain MAP> 65 mm hg

Inj.Lasix 40 mg/IV/TID if SBP> 110mm hg

Inj.Pantop 40mg/IV/OD

Inj.Zofer 4mg/IV/SOS

TAB.Shelcal 500mg/PO/BD

TAB.Nodosis 550 mg/PO/BD

CAP. Alpha D3 0.25 mcg/PO/OD

INJ.Augmentin 1.2gmIV/BD

TAB.Ultracet/PO/BD

SYP.Ascoryl-LS/PO/TID

TAB.Dolo 650mg/PO/SOS if fever 

Strict I/O charting

PR/BP/SP02 charting hourly 

Protein powder 2 tsp in 1 glass of milk twice daily

Nebulisation with Duolin-8th hourly mucomist-8th hourly 

Budecort-12th hourly

Inj.Optineuron 1 amp in 500 ml /NS/IV/OD 

            


ECG

Chest X Ray:


X ray on day 3:

IMPRESSION
Bilateral costophrenic angles are obliterated

Bilateral pleural effusion is present

ABG on day 1

ABG on day 2:


ABG on day 3:


Ultrasound abdomen:

RFT on day 1


 RFT on day 2:

RFT on day 3:



LFT:


Thyroid function tests:



Blood for culture and sensitivity:


Urine for culture and sensitivity:



Hemogram on day 1

Hemogram on day 2

Serum Iron:


Serum ferritin: 

APTT:

Reticulocyte count:



Peripheral smear:


Blood grouping and RH typing:


 Peripheral smear:

Dengue NS1 Antigen, Ig G and Ig M 

Blood for MP Strip test

LDH:


CUE on day 1:
CUE on day 2:


Urine protein /creatinine ratio:

Urinary electrolytes Na,K

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