45 yr old male with fever, abdominal pain ,loose stools and vomitings

CHIEF COMPLAINTS :

   A 45 yr old male c/o fever since 5 days, abdominal pain , loose stools and vomitings since 14/10/2022.

HOPI:

patient was apparently asymptomatic 5 days ago and then developed fever, which is low grade, not associated with chills and rigors and relieved on medication. He complains of diffuse pain abdomen since 11th October morning. He had 3-4 episodes of vomiting on the same day evening, food particles as content and non- bilious in nature .He had loose stools since evening the same day, which is of 5 -6 episodes and so he went to local hospital. He developed weakness of both upper and lower limbs and found to be having low potassium, correction was done and the weakness got improved. He now came with c/o abdominal pain , vomiting and loose stools.

PAST HISTORY

Not a k/c/o DM, Hypertension, Asthma, epilepsy, CAD, CKD. 

He went for a General checkup 6yrs ago, where he was diagnosed as HIV positive. He was on ART . 

He met with an accident 3yrs ago and got Right ankle fracture, followed by malunion . 

No significant family history.

PERSONAL HISTORY:

Diet- mixed

Appetite-normal

Bowel and bladder movements- regular.

Addictions- occasional toddy consumption.

Allergies- none

General examination:

Patient is conscious, coherent and cooperative. Well oriented to time, place and person.

Moderately built and moderately nourished.

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

Vitals:

Temp- 98°F

BP-110/70MMHG

RR-18CPM

PR- 100BPM.

GRBS-155 mg/dl.

Spo2 - 100%

Systemic Examination:

CVS: S1,S2 Heard

RS: B/L Normal Vesicular Breath Sounds Heard. 

P/A: 

On Inspection:

Shape - scaphoid

Abdomen moves equally with respiration. 

Umbilicus inverted

No scars and sinuses present. 

No visible pulsatios , no engorged veins

On palpation:

Right iliac fossa tenderness present

No rebound tenderness, no gaurding, no rigidity

No organomegaly

On percussion: 

No fluid thrill 

No shifting dullness

On Auscultation:

Bowel sounds heard

ORAL CANDIDIASIS

HIV MEDICATION:

TREATMENT GIVEN:

1) IV FLUIDS(2units NS, 1unit RL) @100ml/hr.

2) INJ. CIPROFLOXACIN/IV/OD.

3) INJ. METROGYL 500MG/IV/TID.

4)INJ PAN 40MG/IV/BEFORE BF.

5) INJ. BUSCOPAN/IM/BD.

6) CAP. RETODRIL 100MG/PO/TID.

7) TAB. SPORLAC-DS ,2TAB/PO/TID.

8) ORS SACHETS IN 1LITRE OF WATER, 200ML TO BE TAKEN AFTER PASSAGE OF EACH STOOL. 

9)T.Fluconazole 200mg po/stat f/b 100mg po/od.

10) MONITOR VITALS. 

11) INFORM SOS. 

DIAGNOSIS:

ACUTE GASTROENTERITIS WITH PRE RENAL AKI SECONDARY TO ACUTE GE , HIV POSITIVE SINCE 6YRS AND ON ART MEDICATION.