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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