?IRRITABLE BOWEL SYNDROME MIXED TYPE, DIARRHEA WITH MALABSORPTION SYNDROME WITH DIABETES MELLITUS WITH AKI IN CKD TREATMENT: INJ. HAI SC/TID TAB LASIX 20 MG PO BD T

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A 41 YEAR OLD MALE CAME TO THE OPD WITH THE COMPLAINTS OF LOOSE WATERY STOOLS SINCE 2 YEARS, NAUSEA AND VOMITING SINCE 10 DAYS. PATIENT WAS EVALUATED CLINICALLY AND WITH APPROPRIATE INVESTIGATIONS  WAS PROVISIONALLY DIAGNOSED DIARRHEA WITH MALABSORPTION SYNDROME WITH DIABETES MELLITUS WITH AKI IN CKD

THE PT WAS STARTED ON CONSERVATIVE MANAGEMENT ( INJ. HAI SC/TID, TAB SPOROLAC PO TID, TAB LASIX 20 MG PO BD, TAB OROFER XT PO OD )

GENERAL EXAMINATION- 

THE PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE

MODERATELY BUILT AND NOURISHED

SIGNS OF PALLOR 

NO ICTERUS, CYANOSIS, CLULBBING, EDEMA 

VITALS:

TEMP: AFEBRILE

PR: 68 BPM

RR: 16 CPM

BP: 120/70 MM HG

SPO2: 95% @ RA

GRBS: 82 MG/DL

CVS: S1, S2 HEARS, NO MURMURS

RS: BAE+, NVBS

TRACHEA: CENTRAL

NO DYSPNOEA AND WHEEZE

NO RHONCHI

ABDOMEN:  TENDER, SOFT, DISTENDED, 

LIVER AND SPLEEN NOT PALPABLE

BOWEL SOUNDS NOT HEARD

CNS:

LEVEL OF CONSCIOUSNESS: CONSCIOUS, ALERT

SPEECH: NORMAL

NECK STIFFNESS ABSENT

KERNINGS SIGN ABSENT

CRANIAL NERVES: NORMAL

MOTOR SYSTEM: NORMAL

SENSORY SYSTEM: NORMAL

GCS: 15/15 E4V5M6

TONE:

UL: NORMAL

LL: NORMAL

POWER:

UL: BOTH 5/5

LL: BOTH 5/5

REFLEXES:             RT              LT

B:                           +2              +2

T:                           +2              +2

S:                           +1              +1

K:                           +2             +2

A:                           +2              +2

 

 

NEPHROLOGY REFERAL DONE ON 27/12/23 I/V/O HIGH SERUM UREA AND CREATININE

TREATMENT

INJ LASIX 40 MG IV BD

TAB NODOSIS 500 MG PO BD

TAB OROFER XT PO OD

TAB SHELCAL CT PO OD

USG-

FINDINGS 

E/O 5 MM CALCULUS NOTED IN MID POLE OF RIGHT KIDNEY

 

IMPRESSION

B/L GRADE II RPD CHANGES

RIGHT RENAL CALCULUS

 

 

 

 

 

 

COMPLETE URINE EXAMINATION (CUE)   26-12-2023 05:39:PM  COLOUR Pale yellow    APPEARANCE Clear    REACTION Acidic    SP.GRAVITY 1.010    ALBUMIN Nil    SUGAR Nil    BILE SALTS Nil    BILE PIGMENTS Nil    PUS CELLS 2-3    EPITHELIAL CELLS 2-3    RED BLOOD CELLS Nil    CRYSTALS Nil    CASTS Nil    AMORPHOUS DEPOSITS Absent    OTHERS Nil	RFT   26-12-2023 05:42:PM  UREA 104 mg/dl 42-12 mg/dl  CREATININE 6.3 mg/dl 1.3-0.9 mg/dl  URIC ACID 6.4 mg/dl 7.2-3.5 mg/dl  CALCIUM 10.0 mg/dl 10.2-8.6 mg/dl  PHOSPHOROUS 2.9 mg/dl 4.5-2.5 mg/dl  SODIUM 139 mEq/L 145-136 mEq/L  POTASSIUM 4.7 mEq/L 5.1-3.5 mEq/L  CHLORIDE 104 mEq/L 98-107 mEq/L
LIVER FUNCTION TEST (LFT)   26-12-2023 05:42:PM  Total Bilurubin 0.58 mg/dl 1-0 mg/dl  Direct Bilurubin 0.18 mg/dl 0.2-0.0 mg/dl  SGOT(AST) 10 IU/L 35-0 IU/L  SGPT(ALT) 10 IU/L 45-0 IU/L  ALKALINE PHOSPHATE 159 IU/L 128-53 IU/L  TOTAL PROTEINS 6.6 gm/dl 8.3-6.4 gm/dl  ALBUMIN 4.3 gm/dl 5.2-3.5 gm/dl  A/G RATIO 1.87	HBsAg-RAPID   26-12-2023 05:42:PM Negative
Anti HCV Antibodies - RAPID   26-12-2023 05:42:PM Non Reactive	STOOL FOR OCCULT BLOOD   27-12-2023 10:09:AM Negative (-ve)
RFT   30-12-2023 06:32:AM  UREA 92 mg/dl 42-12 mg/dl  CREATININE 5.9 mg/dl 1.3-0.9 mg/dl  URIC ACID 4.9 mg/dl 7.2-3.5 mg/dl  CALCIUM 10.1 mg/dl 10.2-8.6 mg/dl  PHOSPHOROUS 3.0 mg/dl 4.5-2.5 mg/dl  SODIUM 137 mEq/L 145-136 mEq/L  POTASSIUM 4.2 mEq/L 5.1-3.5 mEq/L  CHLORIDE 104 mEq/L 98-107 mEq/L

DIAGNOSIS:

?IRRITABLE BOWEL SYNDROME MIXED TYPE, DIARRHEA WITH MALABSORPTION SYNDROME WITH DIABETES MELLITUS WITH AKI IN CKD

TREATMENT:

INJ. HAI SC/TID

TAB LASIX 20 MG PO BD

TAB OROFER XT PO OD 

TAB SPOROLAC PO TID X 7 DAYS