General Medicine Case history -4

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Date of admission- 12/09/2021

A 70-year-old farmer by occupation came, with a chief complaint of stomach ache for 15 days, pedal oedema (on and off ), shortness of breath on exertion since 2 months, loose stools 4-5 episodes around three days back and got subsided, with decreased urine output for 3 days, high-grade fever since 4 days, got receded, drowsiness since 2 days.

HISTORY OF PRESENT ILLNESS: 

The patient was asymptomatic 15 days back. Pedal oedema (on and off ), shortness of breath on exertion since 2 months, loose stools 4-5 episodes around three days back and got subsided, with decreased urine output for 3 days, high-grade fever since 4 days, got receded, drowsiness since 2 days.

HISTORY OF PAST ILLNESS:  

 She is hypertensive for 30 years and using medication since then. A hysterectomy was done around 40 years ago.No history of asthma, TB, Diabetes mellitus. 

PERSONAL HISTORY : 

The patient has an active addiction to chewing betel leaf. 

FAMILY HISTORY : 

No significant history.

General examination:

The patient is conscious.

Pallor +

Icterus +

Pedal oedema (B/L) +

No clubbing, cyanosis, koilonychia, generalized lymphadenopathy.

Vitals at the time of admission : 

Temperature - afebrile

Pulse Rate  -98 BPM

BP - 80/40 mm Hg

Spo2 - 98% at Room air

Respiration count - 22 /min

General random blood sugar - 120 mg%

Systemic examination : 

Cardiovascular system : 

S1S2 +

Respiratory system : 

Normal vesicular breath sound 

 Central Nervous system : 

No appreciable disease. 

Investigations 

Ultrasound of abdomen is suggested .

Provisional Diagnosis : 

AKI on CKD ? HTN

HF? DCMP?

Investigations (Reports ):

Final Diagnosis : 

Acute kidney injury on Chronic kidney disease (acute tubular necrosis ) 2° to acute GE.

K/C/O : HTN , HF, ( DCMP?)

Treatment : 

Patient is advised to do dialysis twice a week under medication and maintaining proper diet.

Dialysis started on 13 September, 2021 

2nd - 14th sep , 2021

3rd- 15th sep , 2021 

4th - 19th sep , 2021.