G.Preethi , 1601006057, roll no :50

 56Y old female came to OP with chief complaints of

 fever since 1 month

 B/L swelling of lower limb since 1month 

 Loss of apetite since 20 day

Generalised weaknesa since 20 days

Vomitings since 3 daysdays

History of present illness : 

- Fever was high grade, intermittent not associated with chills and rigors , cold and cough.

- Associated with decreased apetite and generalised weakness, burning micturation was on and off and associated with suprapubic pain

- Swelling of lower limbs was on and off since 2 years and not associated with SOB, palpatations, decreased urine output, facial puffiness

- on presentation pedal edema was not seen.                                                                    

patient denied the history of usage of Nsaids . Patient was apparently asymptomatic 10 yrs back had severe menstrual flow , consulted a gynaecologist . She was advised  for hysterectomy-operated and biopsy was done  .                                   

- History of past illness :      after 6 months(2012) of hysterectomy on general follow up she was diagnosed as DM-2 and on tab -metformin (500mg po/od    Patient was on regular medication. Intermittent tingling sensation of B/L   LL+.  



 Treatment history : 
diabetic-10 yrs . 
Metformin 500mg po/od            
 Surgeries - hysterectomy.   


 -Personal history :  Married                                         

Occupation:daily labourer.                                

Appetite:lost (20yrs)                                                      

Diet :non vegetarian.                                                 

Bowels :regular                                                          

Bladder : abnormal (burning micrurition ( intermittent)           

Habits : alcohol - no                                                

Tobacco-no.                                                                   

Drug uses - no      

                                                                                 

Family history- not relevant. 

Menstrual history   :  
Age of menarchae -12 yrs  

 Obstetric history - 
Age at marriage - 14 yrs
Age at first child birth. - 16 yrs.        
 gravida - 5 ,para -5  ,
Still birth :- no , no of living children :5                                      No abortions 
Birth history : FTND , no history of birth asphyxia.                       Developmental history-normal.    

 Physical examination    :

General :    
                                                                                      

Pallor :++.                                                                    

Icterus :no.                                                               

Cyanosis :no.                                                          

Clubbing :no.                                       

Lymphadenopathy:no.                                              

Oedema of feet : no.                                          

Malnutrition: no.                                               

Dehydration: no.                                              

Temperature:afebrile     
 
PR:106bpm.                                                         

RR:18cpm.                                                     

BP:110/80mm Hg.                                                         

Spo2: at room air -96%.                                              

GRBS -166mg%.

Systemic examination:  
                                                
CVS : s1, s2 heard 
                                                                             

Respiratory system : 

BAE +

 trachea central in position  

NVBS + 
 


Abdomen : normal.  

                                                                                       

CNS : NAD     


Provisional diagnosis 
      

AKI on CKD with  k/c/o DM-2 since 10 yrs with  anemia under evaluation.

                                                                         Investigations :  

USG :


  RBS : 


Serum creatinine:(22/6/21)



FBS:


HBA1c:



Serum creatinine (23/6/21):


Blood urea :





ECG : 

Urine protein /creatine ratio (24 /6)

Serum creatinine (25/6)

Blood urea ( 25/6)


Serum electrolytes (25/6 )

 

ABG : 




Urine culture 


Sputum culture :


Treatment :

Day -1 

Vitals :
Temperature:98.6•F
PR:102bpm 
Bp :110/60mm hg 
GRBS : 176mg/dl 


IVF - uo +30 ml /hr 
Tab Lasix 
Tab :orofer 
Tab :nodosis 
Inj : HAI  s/c acc to sliding scale 
GRBS charting 
 
Day :2

Vitals : 
Temperature: a febrile 
PR : 108bpm
BP:120/70mmhg 
GRBS :176mg/dl 


Ivf-uo +30 ml/hr 
Inj pantop 
Inj zofer
Inj :Lasix 
Tab :orofer 
Tab :nodosis 

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