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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