Case 2
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A 52 years old male patient presented to the opd with chief complaint of swelling of the body parts with fever and vomitings.
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 4 years ago, then developed swelling of body parts fever and vomitings.
4 years ago patient had recurrent fever for which he visited the hospital, where he diagnosed as acute kidney injury. Later presented to KIMS for further evaluation.
The patient had decreased urine output, swelling in the abdomen and pedal edema.
PAST HISTORY
Patient is a K/C/O hypothyroidism since 10 years.
Patient had a known history of NSAID's use 7 years ago.
Patient is a K/C/O hypertension 4 years ago
Blood transfusion 4 years ago.
There is no history of any major surgeries.
No history of diabetes, T.B, Asthma, CAD.
PERSONAL HISTORY
Patient consumes mixed diet.
Normal bowel movements and decreased urine output.
He had adequate sleep.
Patient is alcoholic and has a habit of smoking which he quit 10 years ago.
FAMILY HISTORY
No history of similar complaints in any of the family members.
TREATMENT HISTORY
Patient has diagnosed as AKI in previous hospital.
Patient is on medication for hypothyroidism.
No history of drug allergy.
GENERAL EXAMINATION
Patient is conscious, coherent and co-operative. Well oriented to time, place and person. Normal built and nourished
There is bilateral pedal edema and pallor.
No history of cyanosis, clubbing, icterus.
No generalised lymphadenopathy.
Vitals
Temperature:98°f
Respiratory rate:18 cycles/min
Pulse rate:95 beats/ min
B.P:130/80mm hg
SpO2:96%
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge
No visible pulsations, engoreged veins, scars, sinuses.
Palpation:
JVP:normal
Auscultation:
S1, S2 are heard. No murmurs
RESPIRATORY SYSTEM
Bilateral airway+
Position of trachea- central
Normal vesicular breath sounds - heard
No added sounds
PER ABDOMEN
abdomen is scaphoid shape
Non-tender, soft
Ascites is present
Bowel sounds heard
CENTRAL NERVOUS SYSTEM
Patient is conscious
Reflexes are normal
Speech is normal
INVESTIGATIONS
COMPLETE BLOOD PICTURE
Hb :- 9.3gm/dl
Total count:- 7000 cells/cumm
Neutrophils :- 62%
Lymphocytes :-25%
Eosinophils :- 5%
Monocytes :-8%
Basophils :- 0%
Platelets :- 1.52 lakhs/cumm
Smear :- normocytic normochromic anemia
RENAL FUNCTION TEST
Urea:- 99mg/dl
Creatinine:- 7.1 mg/dl
Uric acid:- 8.7 mg/dl
Calcium:- 9.0mg/dl
Phosphorus:-3.3mg/dl
Sodium:- 140mEq/l
Potassium:- 3.5 mEq/l
Chloride:- 102mEq/l
SERUM IRON :- 78 ug/dl
PALLOR
PEDAL EDEMA
ULTRASOUND REPORT
Tab NICARDIA 20 mg PO/ TID
Tab PANTOP 40 mg PO/ OD
Tab LASIX 40mg PO/ BD
Tab Bio - D3 PO/ OD
Tab OROFER - XT PO/ OD
Tab NODOSIS 500mg PO/ BD
Tab SHELCAL 500mg PO/ OD
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