60yr old female with loose stools and decreased urine output since 1 day

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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  

A 60 year old female home maker by occupation came to casualty with cheif complaints of loose stools since yesterday and c/o decreased urine output since today morning  

History of presenting illness:-

Pt was apparently asymptomatic till yesterday morning, then she developed loose stools (7-8 episodes till today mornin), which are watery in consistency, non blood tinged,non mucopurulent associated with abdominal pain and fever ( low grade not associated with chills and rigor).Now abdominal pain and loose stools subsided. 

Patient also has c/o decreased urine output (anuria) since today morning which is previously  not associated with dribbling of urine,hesitancy, urgency, burning micturition ,

H/o toddy consumption 2 days ago 

Past History:-

K/c/o DM-2 since two years ( on Tab metformin 500mg po/od)

K/c/o HTN since 2 years ( on tab amlodipine 5mg+tab lisinopril 5mg)

K/c/o hypothyroidism  since 2 years ( on tab thyronorm 50 mcg)

N/k/c/o cad,cva,epilepsy, tb,asthma

Daily Routine:

Patient wakes up in the morning around 6 am freshens up and does her daily chores. Her grandchildren live with her during the school year so she gets them ready and sends them to school  She has breakfast at around 10 am usually consisting of chapati or upma. She then relaxes for some time and waits for her grandchildren to come back at 1 and has lunch with them. Afterwards she passes time by taking a nap and chatting with her neighbours. She then has dinner at 7 and sleeps by 8 pm. The patient's attender says she has been more irregular with meals since the past 2 years after her husband passed away. 

Personal history:-

Diet - vegetarian 

Appetite- adequate 

Sleep-adequate 

Bowel and bladder movements- reduced micturition since today morning ,bowel movements regular 

Addictions- occasional toddy drinker 

General examination:-

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

Pallor, icterus,cyanosis ,clubbing, lymphadenopathy,bilateral pedal edema abscent 

Vitals :-

PR-98 bpm

BP-100/60 mmhg

RR-18 cpm

Spo2- 99% @ RA

GRBS-120 mg% 

Systemic examination:-

PA:

Inspection: 

Round, large with no distention

Umbilicus: Inverted

No visible pulsation,peristalsis, dilated veins and localized swellings. 

Palpation: 

Soft, tenderness present in epigastric region

No signs of organomegally 

Percussion: 

No fluid thrill, shifting dullness absent 

Auscultation: 

Bowel sounds heard 2-3/ minute 

CVS: 

Inspection: 

There are no chest wall abnormalities 

The position of the trachea is central. 

Apical impulse is not observed. 

There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 

Palpation: 

Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 

Position of trachea was central 

Auscultation: 

S1 and S2 were heard 

There were no added sounds / murmurs. 

RESPIRATORY SYSTEM: 

Bilateral air entry is present 

Normal vesicular breath sounds are heard. 

CNS: 

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact 

CRANIAL NERVES :Normal 

SENSORY EXAMINATION 

Normal sensations felt in all dermatomes 

MOTOR EXAMINATION 

REFLEXES 

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

CEREBELLAR FUNCTION 

Normal function 

No meningeal signs were elicited

Provisional diagnosis:-

ACUTE KIDNEY INJURY (RENAL) ON ?POST RENAL (! STRICTURE URETHRA)  CHRONIC KIDNEY DISEASE ( STAGE 5 ESRD) WITH ? SEPTIC SHOCK WITH OSTEOARTHRITIS

B/ L KNEES 

HTN PRESENT, DM PRESENT, HYPOTHYROIDISM PRESENT 

INVESTIGATIONS

Hb 8.2 gm/dl

TLC 7200

N/L/E/M 77/18/1/4

PCV 25.6

PLT 2.23

SMEAR Microcytic hypochromic

RFT

Urea 121

Creatinine 7.5

Uric acid 10.4

Ca 8.8

P 6.0

Na 136

K 4.0

Cl 102

ABG

ph 7.27

pCO2 18.8

PO2 85.1

HCO3 8.5

Blood Lactate 16

Serum iron 34

Treatment:-

1.Salt restriction < 2g / day

2.Fluid restriction < 2l/ day

3.IVF ns,rl,@ u.o +30 ml/hr

4.Inj noradrenaline 1amp + 46 ml ns @ 5ml/ hr( 18mg/hr) increase/ decrease to maintain MAP >65 mmhg

5.inj Lasix 40 mg/iv/od ( if sbp >100 mmhg after informing icu/ nephritis pg )

6. Inj sodium bicarbonate  25meq + 100 ml ns slowly over 30 min 

7.tab thyronorm 50 mcg/po/od/bbf 

8.tab nodosis 500mg/po/ bd

9.tab orofer- xt /po/od (1-×-×)

10. Tab shelcal / po/ od (×-1-×)

11. Monitor vitals 

12. Strict io charting 

13. Inj neomol 1g/iv/ if temp >101 f

15. Tab dolo 650 MG/ po/sos

16. Tepid sponging 

17. Inj Piptaz 4.5 gm iv/ Stat ( day 1)

                           F/b 

         Inj piptaz 2.25 gm iv/ tid