1 Vaishnavi harinarthini
A 70 yr old female was brought by his son to the opd with the complaints of shortness of breath and bilateral pedal edema
chief complaints:
shortness of breath since one week
bilateral pedal edema since five days
decreased urine output
HISTORY OF PRESENTING ILLNESS:
patient was apparently normal 5-6 years back.then she developed low grade fever on and off with generalised weakness and went to healthcare and diagnosed with diabetes.
one month back she had loose stools in small quantity3-4 episodes per day for 1-2 days .
since one week she deveolped shortness of breath initially on exertion but now at rest.bilateral pedema initially on ankle then generalised;facial puffiness and decreased urine output
HISTORY OF PAST ILLNESS
history of diabetes:5-6 yrs
no history of hypertension,tb,epilepsy
FAMILY HISTORY:
Not a k/c/o asthma,tb.epilepsy.htn
PERSONAL HISTORY:
married
occupation:daily wage labourer
diet:mixed
appetite:low
bowel and bladder movements are abnormal
no allergies
used medications for diabetes
GENERAL EXAMINATION
Physical examination:
moderately built
presence of pallor
no icterus
no cyanosis
no lymphadenopathy
bilateral pedal edema
VITALS:
pulse rate:84/min
respiratory rate:22/min
BP:130/70
SYSTEMIC EXAMINATION:
CVS
s1 and s2 heard
no murmurs
no thrills
RESPIRATORY SYSTEM:
Dyspnoea
no wheezing
position of trachea is central
breath sounds are vesicular
ABDOMEN
No tenderness and no palpable mass
No bruits
liver and spleen are not palpable
bowel sounds are present
CENTRAL NERVOUS SYSTEM;
Conscious and coherent
speech is normal
no neckstiffness
sensory and motor system are intact
PROVISIONAL DIAGNOSIS:
AKI ON CKD
INVESTIGATIONS:
TREATMENT:
13/06/2022
IV FLUIDS
INJ LASIX 40MG/IV/TWICE A DAY
INJ PAN 40MG/IV/ONCE A DAY
INJ ZOFER 4MG/IV
TAB NODOSIS 500MG/TWICE A DAY
TAB OROFER-XD/ONCE A DAY
TAB SHELCAL 500MG/ONCE A DAY
TAB MVT/ONCE A DAY
INJ HAI THREE TIMES A DAY according to grbs
14/06/2022
IV FLUIDS
INJ LASIX 40MG/IV/TWICE A DAY
INJ PAN40 MG/IV/ ONCE A DAY
INJ ZOFER4 MG/IV
TAB NODOSIS 500 MG/TWICE A DAY
TAB OROFER-XD ONCE A DAY
TAB SHELCAL 500MG ONCE A DAY
TAB MVT/ONCE A DAY
INJ AUGMENTINE 625MG/TWICE A DAY
INJ HAI according to grbs
15/06/2022:
IV FLUIDS
INJ LASIX 40MG/IV/ TWICE A DAY
INJ PAN 40MG/IV/ONCE A DAY
INJ ZOFER 4MG/IV
TAB NODOSIS 500MG/TWICE A DAY
TAB OROFER-XD ONCE A DAY
TAB SHELCAL 500MG/ONCE A DAY
TAB MVT ONCE A DAY
INJ AUGMENTIN -625MG TWICE A DAY
INJ HAI according to grbs
16/06/2022 :
FLUID AND SALT RESTRICTION
INJ LASIX 40MG/IV/TWICE A DAY
INJ PAN 40MG/IV/ONCE A DAY
INJ AUGMENTIN -625MG TWICE A DAY IV
TAB NODOSIS 500MG ONCE A DAY
TAB OROFER-XD ONCE A DAY
TAB SHELCAL 500MG ONCE A DAY
TAB MVT ONCE A DAY
INJ HAI ACCORDING TO GRBS THRICE A DAY
TAB NICARDIA 20MG/TWICE A DAY
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