LONG CASE
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65 years old female patient who is from nalgonda labor by occupation presented to OPD on 12-01-23
CHEIF COMPLAINTS:
Patient complaints ofabdominal pain since 4days and associated with nausea and vomiting since 2days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 years back then she developed pedal edema, facial puffiness, decreased urine output ,shortness of breath and difficulty in moving lower limbs 2 years back and was taken to a private hospital and diagnosed to have hypokalemic and found to have raised creatinine levels
1 year back patient started walking with support and decreased pedal edema and facial puffiness and decreased urine output and diagnosed with CKD ( increased creatinine, shrunken kidney.) anemia .
2months back pain in abdomen, decreased appetite, burning micturition and cloudy urine for 6 days subsided on medication.
2days back pain in abdomen - diffuse, squeezing type not associated with loose stools
Vomiting,nausea and pain abdomen ,Non bilious ,non projectile, 2 episodes, food particles as content.
PAST HISTORY:
N/K/C/O DM, TB, HTN , EPILEPSY,ASTHMA.
No history of past surgery
Blood transfusion 2months back 2prbc
FAMILY HISTORY:
No similar complaints in family
PERSONAL HISTORY:
APPETITE : decreased
DIET: mixed
SLEEP : Adequate
BOWEL AND BLADDER : regular
MICTURITION : decreased
Addictions: Alcohol occasionally (stopped 10 years back)
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative, well oriented to time,place and person.
Thin built and moderately nourished
No signs of Icterus cyanosis, clubbing , Lymphadenopathy.
Pallor:present
Vitals
Temp:afebrile
PR: 90 bpm
Bp: 120/80 mmHg
RR: 20 cpm
SYSTEMIC EXAMINATION :
RESPIRATORY SYSTEM-:
On inspection:
Chest is bilaterally symmetrical
Trachea – central
No Drooping of shoulders,
No suprasternal and supraclavicular notching is present
No Sinuses, scars, dilated veins, nodules
Movement with respiration bilaterally symmetrical
On palpation:
No local rise of temperature
No tenderness
All the inspectory findings are confirmed.
Trachea - central
No Intercostal widening/crowding of ribs
Chest movement symmetrical
Measurement of Chest expansion -
Whole thorax expansion :36 inspiration
34 expiration
Hemi thorax expansion :17
Vocal Fremitus: normal
On percussion:
Resonant sounds are heard
Dull notes from 5th intercoastal area
On auscultation:
Normal Vesicular Breath sounds
No Added sounds
Vocal Resonance vibrations are heard
CVS-:
No raised jvp
On inspection:
Bilaterally symmetrical chest
No visible pulsations
No scars /sinuses
No engorged veins
On palpation :
Apex beat :at 5th intercoastal space
No thrills
On Auscultation :
S1 &S2 are heard
No murmurs are heard
ABDOMEN:
On inspection:
shape : obese
Flanks : full
Umbilicus: central and inverted
No engorged veins
No visible pulsations
No scars
No Hernial Orifices
On palpation :
No local rise of temperature
Tenderness present in right iliac region.
No palpable masses
No organomegaly
On percussion:
No ascites
No fluid thrill
No shifting dullness
Auscultation :
Bowel sounds present
No bruits
CNS-:
Consious, coherent ,cooperative
Speech normal
No neck stiffness
No meningeal signs
Motor system : normal
Sensory system: normal
Able to percieve-:pain , temp.
Cranial nerves : intact
No cerebellar signs
INVESTIGATION:
Serum creatinine -8.6mg/dl
Blood urea -235mg/dl
Serum pottasium-4.0mmol/lit
Random blood sugar -121mg/dl.
Provisional Diagnosis:
Acute kidney injury on chronic kidney disease with urinary tract infection.
Treatment:
T.LASIX 40MG PO/OD
T.SHELCAL 500MG PO/OD
CAP.BIO N PO/Once weekly
T.OPOFER ×T PO/OD
Inj.EPO 4000 iu S/C /Once weekly
T.NODOSIS 500MG PO/BD
syp.CITRALKA 15ML PO/HS
Syp. MUCALINEGEL PO/BD
T.DOLO 650MG PO/SOS
Inj.MONCEF 1GM /IV/BD
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