CC: Vomiting, diarrhea, lightheaded.
HPI: 74F with HTN, T2DM and HLD with 3 days of nonbloody watery diarrhea (6-8/day) and vomiting, unable to keep fluids down x24 h. Husband had the same illness last week, now recovered. Lightheaded on standing. No abd pain, fever, or recent antibiotics.
Vitals: T 37.4, HR 104, BP 102/58 (orthostatic drop to 84/50 standing), RR 18, SpO2 98% RA.
Exam: Dry mucous membranes, poor skin turgor. Abd soft, hyperactive BS, nontender.
Labs: Na 128, K 3.7, Cl 94, HCO3 20, BUN 52, Cr 2.3 (baseline 0.8, 04/2026), Glu 162. WBC 9.1. Lipase normal. UA: SG 1.030, no infection.
Assessment/Plan:
1. AKI, likely prerenal from dehydration due to gastroenteritis. 2 L NS bolus, ondansetron.
2. Hyponatremia.
Dispo: Admit to medicine.
HISTORY AND PHYSICAL
HPI: See ED. Tolerating sips after ondansetron.
PMH: HTN. T2DM (A1c 6.9%, no complications). HLD.
Meds: lisinopril/HCTZ 20/12.5 mg daily, metformin 500 mg BID, simvastatin 20 mg qHS.
Exam: HR 96, BP 112/64, mucosa dry. Abd benign.
Assessment/Plan:
1. Acute kidney injury - prerenal, due to dehydration from viral gastroenteritis. Cr 2.3 from baseline 0.8. NS at 125 mL/h, hold lisinopril/HCTZ and metformin, strict I/O, BMP q12h.
2. Dehydration - IV fluids as above.
3. Hyponatremia, hypovolemic - Na 128 from GI losses; isotonic fluids, goal correction <8 mEq/L per 24 h.
4. Viral gastroenteritis - likely norovirus given sick contact; supportive care, ondansetron PRN, advance diet. Stool studies not indicated.
5. T2DM - hold metformin; correction scale insulin.
6. HTN - hold antihypertensives while hypovolemic.
7. HLD - continue simvastatin.
Pt resting, husband at bedside. NS infusing at 125 mL/h. No emesis since arrival on unit; one loose watery stool at 20:15. Tolerating clear liquids and crackers. Orthostatic vitals: lying BP 118/66 HR 88, standing BP 104/60 HR 102, mildly lightheaded on standing; fall precautions and call light within reach. Voided 300 mL concentrated urine.
Nutrition screen triggered by poor PO intake x3 days. Ht 160 cm, Wt 69 kg, BMI 27.0; usual weight 70 kg (1.4% loss, acute, from fluid losses). Eating 50-75% of soft diet today, no further nausea. Does not meet ASPEN criteria for malnutrition. Recommend advance to consistent-carbohydrate diet as tolerated, encourage oral fluids 2 L/day once home, oral rehydration education provided.
Date Na K BUN Cr
09/25 128 3.7 52 2.3
09/26 AM 132 3.9 38 1.6
09/26 PM 134 4.0 30 1.3
09/27 137 4.1 19 1.0
HOSPITAL DAY 3
S: No vomiting since admission, one loose stool yesterday. Eating soft diet.
O: HR 78, BP 132/76, orthostatics negative. Mucosa moist.
Assessment/Plan:
1. AKI - prerenal, resolving, Cr 1.0.
2. Hyponatremia - corrected, Na 137.
3. Viral gastroenteritis - resolving.
4. T2DM, HTN - resume home meds at discharge if Cr stable.
DISCHARGE SUMMARY
Admit: 09/25/2026 Discharge: 09/28/2026 Disposition: Home with husband
DISCHARGE DIAGNOSES:
1. Acute kidney injury, prerenal, due to dehydration from viral gastroenteritis - resolved
2. Hypovolemic hyponatremia - resolved
3. Viral gastroenteritis
4. Type 2 diabetes mellitus
5. Hypertension
6. Hyperlipidemia
HOSPITAL COURSE: IV normal saline with steady improvement; Cr 2.3 -> 0.9, Na 128 -> 138. GI symptoms resolved by HD2. Metformin and lisinopril/HCTZ resumed at discharge.
FOLLOW-UP: PCP in 1 week with BMP.