22 yr old male with pain abdomen & Vomitings

22 year old male came with chief complaint of

  • Vomitings since 3 days
  • Loose stools since 3 days
  • Pain abdomen since 2 days 

HOPI:

Pt was apparently assymptomatic 3 days back then developed vomitings 10 episodes per day which contained food contents and was associated with nausea. Loose stools 10 episodes on first day and 4-5 episodes on second day which were watery in consistency, non sticky, non foul smelling, non blood stained. Diffuse pain abdomen non radiating.

PAST HISTORY: 

No similar complaints in the past

Not a k/c/o DM,htn,tb,asthma,epilepsy 

3 yrs back patient developed fever was diagnosed as typhoid

3 months back patient developed fever was diagnosed as dengue fever 

PERSONAL HISTORY:

He is a student

Consumes vegetarian diet

Appetite reduced

Bowel n bladder regular 

Sleep disturbed because of pain

Addictions: Nil

FAMILY HISTORY:

No similar complaints in family 

GENERAL EXAMINATION:


Pt is conscious, coherent and cooperative 

Moderately built and nourished.

On admission:

BP:126/90mmhg

PR:76bpm

RR:24cpm

SPO2: 99% on RA

GRBS: 92mg/dl










SYSTEMIC EXAMINATION:

CVS: S1,S2, +

RS: BAE+P

R/A: soft, diffuse tenderness in all 9 quadrants 

CNS: NAD

PROVISIONAL DIAGNOSIS: 

?PRE RENAL AKI SECONDARY TO ACUTE GE

INVESTIGATION:-

1yr back

After Admission -

ECG

X-RAY

USG-ABD




Day 1


S:

Rt and lt hypochondrial pain with lower back pain

O: Pt is c/c/c

BP: 160/110 mmhg

PR:90bpm

CVS- S1,S2 heard

RS- BAE+

P/A soft, tender at RT hypochondrial and epigastric region.

CNS- NAD

GRBS- 98mg/dl

Temp- 98f

A:

?PRE RENAL AKI SECONDARY TO ACUTE GE


P:

Tab.vomikind-MD/SOS

Tab.CINOD 5 mg/PO/OD if BP > 140 mmofhg

Strict bp monitoring 

Strict I/O charting 

Temp monitoring


Day 2

S:

Rt and lt hypochondrial pain with lower back pain

O:

Pt is c/c/c

BP: 160/110 mmhg

PR:90bpm

CVS- S1,S2 heard

RS- BAE+

P/A soft, tender at RT hypochondrial and epigastric region.

CNS- NAD

GRBS- 98mg/dl

Temp- 98f

I/O - 2200/1050

A:

?PRE RENAL AKI SECONDARY TO ACUTE GE

P:

Tab.vomikind-MD/SOS

Tab.CINOD 5 mg/PO/OD if BP > 140 mmofhg

Strict bp monitoring 

Strict I/O charting 

Temp monitoring




Day 3

S:Fever spikes +

Dry cough, Pain subsided 

O:Pt is c/c/c

BP: 140/100 mmhg

PR:90bpm

CVS- S1,S2 heard

RS- BAE+

P/A soft, tender at RT hypochondrial and epigastric region.

CNS- NAD

GRBS- 98mg/dl

Temp- 100.9f

A:

?PRE RENAL AKI SECONDARY TO ACUTE GE

P:

Tab.vomikind-MD/SOS

Tab.CINOD 5 mg/PO/OD if BP > 140 mmofhg

Strict bp monitoring 

Strict I/O charting 

Temp monitoring


Day 4

22 Y/M admitted on 23/09/22

S:

Fever spikes +

Dry cough 

Pain Abdomen subsided 

O:

Pt is c/c/c

BP: 140/100 mmhg

PR:90bpm

CVS- S1,S2 heard

RS- BAE+

P/A soft,non tender

CNS- NAD

GRBS- 98mg/dl

Temp- 100.9f

A:

?PRE RENAL AKI SECONDARY TO ACUTE GE

P:

Tab.CINOD 10 mg /po/OD

Tab.MET XL 500mg/po/BD

Tab.NODOSIS 500mg/po/TID.


Day 5

S:

Fever spikes subsided 

Pain subsided 

O:

Pt is c/c/c

BP: 140/90mmhg

PR:82pm

CVS- S1,S2 heard

RS- BAE+

P/A soft, tender at RT hypochondrial and epigastric region.

CNS- NAD

GRBS- 94mg/dl

Temp- 98.4f

A:

AKI on CKD with denovo HTN

P:

Tab.MET XL 50 mg/po/OD

Tab.CINOD 10 mg/po/OD

Tab. NODOSIS 500 mg /po/TID

Strict bp monitoring 

Strict I/O charting 

Temp monitoring



Day 6

S:
Fever spikes subsided
lower back ache  present.

O:
Pt is c/c/c

BP: 140/90mmhg
PR:80pm
CVS- S1,S2 heard
RS- BAE+
P/A soft, non tender.
CNS- NAD
GRBS- 106mg/dl
Temp- 98.4f

A:
AKI on CKD with denovo HTN

P:
Tab.MET XL 50 mg/po/OD
Tab.CINOD 10 mg/po/OD
Tab. NODOSIS 500 mg /po/TID
Day 7

S:
Fever spikes subsided
lower back ache present.

O:
Pt is c/c/c

BP: 150/90mmhg
PR:74pm
CVS- S1,S2 heard
RS- BAE+
P/A soft, non tender.
CNS- NAD
GRBS- 106mg/dl
Temp- 98.4f

A:
AKI on CKD with denovo HTN

P:
Tab.MET XL 50 mg/po/OD
Tab.CINOD 10 mg/po/OD



Day 8

S:
Fever spikes subsided
lower back ache present.

O:
Pt is c/c/c

BP: 140/90mmhg
PR:74pm
CVS- S1,S2 heard
RS- BAE+
P/A soft, non tender.
CNS- NAD
GRBS- 106mg/dl
Temp- 98.4f

A:
AKI with denovo HTN

P:
Tab.MET XL 50 mg/po/OD
Tab.CINOD 10 mg/po/OD
Tab. NODOSIS 500 mg /po/TID
Tab.PREGABALIN N 75 mg/PO/OD@9pm
Underwent 4 th session of dialysis .



Day 9

S:
Fever spikes subsided
lower back ache  present.

O:
Pt is c/c/c

BP: 140/90mmhg
PR:88pm
CVS- S1,S2 heard
RS- BAE+
P/A soft, non tender.
CNS- NAD
GRBS- 106mg/dl
Temp- 98.4f

A:
AKI  with denovo HTN

P:
Tab.MET XL 50 mg/po/OD
Tab.CINOD 10 mg/po/OD
Tab. NODOSIS 500 mg /po/TID
Tab.PREGABALIN N 75 mg/PO/OD@9pm
Underwent 5th session of dialysis .
Hemogram & RFT trends:-


Day 10

S:
lower back ache subsided

O:
Pt is c/c/c

BP: 120/980mmhg
PR:82pm
CVS- S1,S2 heard
RS- BAE+
P/A soft, non tender.
CNS- NAD
GRBS- 106mg/dl
Temp- 98.4f

A:
AKI  with denovo HTN

P:
Tab.MET XL 50 mg/po/OD
Tab.CINOD 10 mg/po/OD
Tab. NODOSIS 500 mg /po/TID
Tab.PREGABALIN N 75 mg/PO/OD


http://shraddhabovolla10.blogspot.com/2022/09/22-yr-old-with-pain-abdomen-vomitings.html

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