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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