A 60 YEAR OLD FEMALE WITH AKI SECONDARY TO CONSUMPTION OF UNKNOWN COMPOUND

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This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

CHIEF COMPLIANTS
vomitings since evening 4hrs - 3episodes 
Loose stools 2 episodes

HOPI
Patient was apparently asymptomatic 4hours back then developed vomitings 3 episodes food as content non bilious non blood stained non projectile 
No h/o outside food intake
No h/o fever 
No h/o abdominal pain 
No sob 

PAST HISTORY
Not a k/c/o htn DM epilepsy Tb asthma

TREATMENT HISTORY
No

PERSONAL HISTORY
appetite normal 
Diet mixed
Bowel and bladder regular
Addictions tobacco snuff

FAMILY HISTORY
no

GENERAL EXAMINATION
 patient is conscious coherent and cooperative

No pallor icterus clubbing cyanosis lymphadenopathy

Vitals 
Temp 98.4F
PR 86 bpm
RR 18  cpm
GRBS 160mg%

SYSTEMIC EXAMINATION 
CVS S1 S2 + no murmurs 
RESPIRATORY 
Trachea central 
Normal vesicular breath sounds
ABDOMEN no tenderness
                    No bruits
                    Liver not palpable
                    Spleen not palpable
                    
CNS. Reflexes 
                      Right   left

Biceps.          +2.       +2

Triceps.         +2.       +2

Supinator.      +2.       +2

Knee.              +2.        +2

Ankle.             +2.        +2

INVESTIGATIONS
05/04/23

HEMOGRAM
LFT
RFT
                                                            
ABG


05/04/23 morning 8 00 AM 



CUE

ULTRASOUND
ECG
PROVISIONAL DIAGNOSIS
AKI secondary to consumption of unknown compound ? Herbicide (penoxulam 1.02%)

TREATMENT
IV FLUIDS RL
INJ IPROFLOXACIN 200mg iv/bd
Inj metrognl 500mg iv /tid
Syp potchlor 15ml po/bd
Tab sporolac po/bd


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