case 2
Name: A. Greeshma
Roll no : 148
Introduction:
65yrs old male came to gen medicine department with chief complaints of bilateral pain and swelling since 10 days , bilateral loin pain since 10 days, fever and chills since 8 days ,bilateral pain in inguinal region since 5 days ,loose stools since 3 days .
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 10 days back ,then he developed complaints of bilateral pedal edema pitty type associated with pain and redness with local rise in temperature .he also had bilateral loin pain 10 days back later he had complaints of fever associated with chills, intermittent,no diurnal variation since 5 days ,he had complaints of pain in bilateral inguinal region for which with all above complaints he was taken to hospital and was diagnosed as AKI on CKD with bilateral lower limb cellulitis , he also had loose stools 3 days back watery not associated with blood which resolved now .
HISTORY OF PAST ILLNESS:
History of blood urine 1 year back after one day resolved on medication
N/k/c/o - HTN , DM , TB , asthma/CAD / epilepsy / CVA
H/o trauma to back after a fall and managed conservatively
PERSONAL HISTORY:
Married
Diet: mixed
Appetite: normal
Bowel movements: regular
Bladder movements: regular
Sleep: adequate
Addictions: alcohol ,tobacco
FAMILY HISTORY:
Not k/c/o DM ,HTN, asthma,tb
PHYSICAL EXAMINATION
General examination:
No pallor
No icterus
No cyanosis
No clubbing
Pedal edema
VITALS
Temperature: 98.7F
Pulse rate: 80/ min
Respiration rate: 12 per min
Bp: 120/80 mm Hg
Systemic examination:
CVS
No thrills
S1S2 present
No murmurs
Respiratory examination:
No dyspnea
No wheezing
Position of trachea is central
Breath sounds are vesicular
Abdominal examination:
Shape of abdomen- scaphoid
No tenderness
No palpable mass
Hernial orifices are normal
Liver not palpable
Spleen not palpable
Bowel sounds no
CNS
level of consciousness- conscious
Speech normal
Signs of meningeal irritation:
a) no neck stiffness
b) no kernigs sign
Cranial nerves normal
motor system normal
Sensory system normal
Reflexes
All are normal
Provisional diagnosis:
AKI on CKD
Treatment:
I.V fluids NS @ 100ml/hr
Inj LASIX 40 mg /i.v /bd
Inj.PIPTAZ 4.5 gm / i.v / stat
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