I am Vinila , student of 5th sem

 A 45 yr old male came to OPD with chief complaints of fever since 4 days associated with left sided loin pain . Patient also presented with breathlessness and abdominal fullness since 2 days .

HISTORY OF PAST ILLNESS 

   Patient is a plumber by occupation and is apparently asymptomatic 14 yrs back later he was on medication for infertility ( he used both herbal and generic medicine ) for 6 months continuously and as a part of health check up he was diagnosed with Diabetes 10 yrs back . He received treatment for infertility irregularly for  about 7 yrs . Patient adopted a girl child 9 yrs back . Patient suffered with loin pain 6 months back for which he was treated by RMP and it was relieved , now since 4 days patient had fever associated with vomitings , chills and rigor. Fever not relived on medication. He also had left lumbar region pain and shortness of breath that relieved on sitting .

HISTORY OF PAST ILLNESS

Patient is a 

K/c/o DM 

Not a k/c/o asthma , hypertension,CAD , tuberculosis.

Family history - not significant 

Personal history 

Bowel and bladder movements - regular 

Appetite decreased since 4 days 

Micturition - normal 

Sleep - normal 

Diet - normal

GENERAL EXAMINATION 

Pallor - no

Lymphadenopathy - no

Clubbing - no

Cyanosis - no

Icterus - no. 

VITALS

BP - 110/70 mmHg 

Respiration rate - 16 / min

Pulse rate - 79 / min

Temperature - 98.4 C/F 

SpO2 - 96%

SYSTEMIC EXAMINATION 

CVS 

No thrills and no murmur 

Cardiac sounds S1 S2 heard 

CNS 

Level of consciousness - conscious 

Speech - normal 

Signs of meningeal irritation - no 

RESPIRATORY SYSTEM 

Position of trachea - central 

wheezing - no 

Dysnea - grade 2 

Breath sounds - vesicular 


PROVISIONAL DIAGNOSIS 

AKI on CKD 

Polycystic kidney disease

K/c/o DM since 10 yrs 

INVESTIGATIONS.






TREATMENT 

On 15/7/2022 

1. Inj meropenem 1gm BD .

2. Inj Lasix 40 mg / ml BD.

3. Inj PAN 40 mg 

4. Inj Zofer 4mg / ml.

5. Tab . Dolo 650 mg 

6. Tab shelcal 500mg 

7. Tab nodosis 500 mg 

On 16 /7/2022

 1.inj meropenem 1gm BD .

2. Inj Lasix 40 mg / ml BD.

3. Inj PAN 40 mg 

4. Inj Zofer 4mg / ml.

5. Tab . Dolo 650 mg 

6. Tab shelcal 500mg 

7. Tab nodosis 500 mg

















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