80 year old male with vomitings and loose stools

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A 80 yr old Male presented with chief complaints of --

Vomitings 3 episodes 

loose 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 diagnosed with ? renal failure and was prescribed some medication and treated accordingly.

Patient c/o 3 episodes of vomitings, non bilious, non projectile, 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 and GRBS showed 500mg/dl then referred here to KIMS
? 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

On examination:
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 Secondary to ? VIRAL INFECTION

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

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

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

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

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

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