Case history 13
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A 57year old female has come to OPD with chief complaints of swelling in the whole body since 3 days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently well and asymptomatic 3 years back and then developed lower back ache .
The pain was continuous and radiating to the groin. The patient visited to the local hospital and she was diagnosed with renal calculi. The medical practitioner has prescribed medication for the calculi.
She had no symptoms till 3 days and 3 days back she developed decreased urine output , shortness of breath.
She also had symptoms such as fever , which was intermittent and not associated with chills but she had cough with sputum. The sputum was yellowish in colour with blood tinged. The cough was intermittent.
PATIENT DAILY ROUTINE BEFORE ILLNESS:
She used get up around 5:30 - 6:00 AM in the morning , patient being a housewife had works like cleaning the house, cooking , after her household work she would have her breakfast at 9:00 AM , with rice . Patient used to eat 3 times a day with no intermittent snacks and all the three times she used to have rice with the curry or curd or dal. Patient would go back to sleep by 9:30 to 10:00 PM in the night and have lunch in between breakfast and dinner around 1:30 to 2:00PM.
PATIENT ALTERED ROUTINE AFTER ILLNESS:
Patient do not complains of any alternation in the routine accept her waking habits have been slightly altered with decreased appitite.
PAST HISTORY:
No history of diabetes, hypertension, epilepsy, tuberculosis in the past.
Patient had not under went any type of surgeries , chemotherapy and radiation therapies in the past.
PERSONAL HISTORY:
Diet: vegetarian
Appitite : lost
Bowel bladder movement: normal.
Addictions : no addictions like alcohol and tobacco smoking.
Family history:
No history of such illness is found the family.
GENERAL PHYSICAL EXAMINATION:
Patient was coherent, cooperative and concious and examined under well lit room
Patient has moderately bulit and nourishment.
No cyanosis, icterus, clubbing and no generalised lymphadenopathy.
Patient with pallor and pedal oedema.
VITAL SIGNS:
Temperature : 98.5degree Fahrenheit
Pulse rate : 98beats /minutes.
BP: 100/60 mmHg.
Respiratory rate:22/minutes.
SpO2:84%
SYSTEMIC EXAMINATIONS
Cardiovascular system:
No thrills and cardiac mummurs .
S1 and S2 are heard .
Respiratory system:
wheezing and dyspnoea is present.
Positioning of trachea is central and breath sounds are vesicular.
Abdomen:
Abdomen is scalloped
No tenderness and no palpable mass is present.Hernial orfices are normal.
No free fluid and bruits and liver and spleen are not palpable .
bowel sounds are not 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:
PROVISIONAL DIAGNOSIS:
CKD in association with right sided pleural effusion with association fever with decreased evaluation.
TREATMENT:
Head end elevation
O2 supplementation (to PO2 >92%)
FLUIDS RESTRICTION <1LIT/DAY.
SALT RESTRICTION <2GM /DAY
INJ.PIPTAZ 0.25MG IV.BD
INJ.CLINDAMYCIN 600MG IV.MD
INJ.LASIX 40MG .IV.BD
ING.ERYTHROPOETIN 4000IU
TAB.NODOSIS 500MG PO.BD
TAB.SHELEAL CT.500MG PO.BD
TAB.OROFER.XT.PO.OD
SYP.ASCORYL .1OML.PO.BD
SYP.LACLUTOSE 2TBSP.PO.BD
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