Case history -9
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A 65year old female has come to casualty with chief complaints of loss of appetite , dry cough,cold and dyspnoea on excretion since 7days.
Patient complaints of facial puffiness , pain in abdomen , shortness of breath since one day
HISTORY OF PRESENT ILLNESS:
Patient was apparently well one week back then she complaints of development of high grade fever , loose stools which subsided on medication and facial puffiness since one day .
PAST MEDICAL HISTORY:
No history of diabetic, hypertension , asthma , Tuberculosis.
No treatment was taken in the past and no surgeries were done in the past.
FAMILY HISTORY:
No revelent family history.
PERSONAL HISTORY:
Diet:mixed
Appitite: normal.
Bowel bladder movement: normal.
Micturition:normal.
No addictions.
GENERAL PHYSICAL EXAMINATION:
Pateint concern was taken and examined in well lit room.
No pallor, cyanosis, icterus, clubbing, pedal oedema.
No generalised lymphadenopathy.
VITAL SIGNS:
Temperature : aferible.
Pulse rate : 90 beats /minutes.
BP: 110/ 70 mmHg.
Respiratory rate:20/minutes.
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills and cardiac mummurs .
S1 and S2 are heard .
Respiratory system:
No wheezing
Presence of dyspnoea.
Positioning of trachea is central and breath sounds are vesicular.
Abdomen:
No tenderness and no palpable mass is present.
No free fluid and bruits and liver and spleen are not palpable .
bowel sounds are heard .
Central nervous system:
Patient is conscious and speech is normal.No signs of meningeal irritation such as neck stiffness and kerning's sign.
Cerebral signs such as finger - nose in coordination and knee - heal incoordination are not present .
INVESTIGATIONS:
Urine sodium:
PROVISIONAL DIAGNOSIS:
Acute kidney injury secondary on chronic kidney disease secondary to viral infection.
TREATMENT:
Tab. Augmentin 625mg PO/OD
Tab.doxcyclin 100mg PO/BD
Inj.lasix 20mg IV/BD
Tab.pan 40mg PO/OD
Syp.Amboxo 10 ml PO/JD
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