gastroenteritis (1601006121)


A 65 year old female with fever,pain abdomen and loose stools.
Chief Complaints :
A 65 yr old woman resident of nalgonda ,a house wife, came with chief complaints of
-fever, pain abdomen, vomiting & loose stools since 1 week -burning micturition since 4 days.

History of presenting illness:

The patient was apparently asymptomatic 1 week back and then developed

-Fever: high grade, intermittent, associated with chills & rigors, relieved with medication

-Lower Abdominal pain : sudden in onset, continuous dull aching/cramping, aggravated with food intake -vomiting 2-3 episodes/day: non bilious, non projectile, watery with food particles

-Loose stools multiple episodes in large volume watery, no tenesmus, no mucous or blood in stools. -History of burning micturition since 4 days : high coloured urine, no hematuria

Past history:
History of similar compliant two months back which were relieved on medication.

History of diabetes type-2 since 10 years and on regular medication
 History of hypertension since 10 years and on regular medication
No history of epilepsy/asthma/siezures.

Treatment history:
Diabetes -metformin 500mg+idaIgliptin 500mg
Hypertension - telmisartan-40mg

Personal history:
Diet: mixed
Appetite: decreased
Bowel movements :irregular
Bladder : incontinenece with burning micturition.
No known allergies
No addictions
Family history:
Not significant
General examination:
Patient is conscious, coherent and cooperative.
Well oriented to time place and person, moderately built,Well nourished

Pallor : present
,lcterus - absent
,Cyanosis absent,
Koilonychia -absent
,Clubbing absent,
Lymphadenopathy - absent,
Edema : facial puffiness present

Vitals:
Temperature: 98.5 0 c afebrile
BP: 120/80 mm hg
Pulse: 110/ min
Respiratory rate :26/min Sp02 :96% at room air
Systemic examination:
ABDOMEN
-Inspection:
Shape- distended ,Flanks full
INVESTIGATION:
Skin over abdomen: multiple vertical and horizontal striae

-Palpation :
Tenderness - diffuse mainly right illac fossa
Liver impalpable

Gall bladder impalpable

Spleen impalpable

-Percussion:
Shifting dullness- not present
Fluid thrill not present
-Auscultation
Bowel sound heard
Other system examination
CVS-Sl , S2 normal
Apical impulse 5th intercostal space 2cm later to midclavicular line. 
No murmurs

CNS
Cranial nerve examination : normal
Reflexes : normal
Investigations:

chest X ray 
haemogram
Complete urine examination
Renal function tests
blood sugar fasting 
FBS - increased

IMPRESSIONS
Renal function tests
Increased serum creatinine levels

 Decreased leucocytes

Urine examination:
Increased pus cells in urine

Ultrasound examination
Single cyst in upper lobe of kidney(incidental finding)

provisional Diagnosis:
Acute gastroenteritis with renal cyst. 

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