A 60 year old male with fever,pedal edema,SOB

Medical case discussion 

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        CASE DISCUSSION

A 60 year old male patient came to medicine opd with chief complaints of fever, pedal edema , since 5days, SOB since 2 days

Patient was apparently asymptomatic 5 days ago then he developed fever in the morning at 4 O clock which is sudden in onset ,continuous in nature not associated with chills and rigors.H/o vomiting one episode ,watery in consistency bilious with food particles , associated with  nausea and watery diarrhea large volume ,5-6 times a day for 2 days.h/o shortness of breath since 2  days.

Past history: 

not a clinical case of hypertension,asthma diabetes,tb ,epilepsy

no history of previous hospital admissions

personal history:

patient works in a nursery , watering plants, after onset of fever 

HIS appetite decreased, sleep decreased , bladder movements regular , no addictions.

treatment history: Nsaid injections for joint pains weekly once for 1 year.

GENERAL EXAMINATION :patient is drowsy ,conscious ,coherent and cooperative , well oriented to time place and person

moderately built and moderately  nourished.

VITALS:

Pulse rate:92 bpm,bounding,high volume regular rhythm

blood pressure:140/90 mm hg in right arm

temperature :99 °F

Respiratory rate :14 cpm

pallor ,icterus, cyanosis,clubbing ,lymphadenopathy

swelling in neck region present,

black papules are seen on palms

ecchymosis present on arm and forearm on right and left hands

SYSTEMIC EXAMINATION:

CVS- S1,S2 heard ,no murmurs

 

RS: NVBS 

CNS: Hmf intact,no focal neurological deficits 

per abdomen:soft,non-tender,no organomegaly

PROVISIONAL DIAGNOSIS: 

ACUTE KIDNEY INJURY

INVESTIGATIONS:

USG

2D ECHO

on 21/3/23

on 22/3/23

FINAL DIAGNOSIS:

ACUTE KIDNEY INJURY 

TREATMENT:

1)INJ.LASIX 40mg/IV/BD

 2) TAB.NICARDIA 10mg /PO/BD

3) TAB.NODISIS 500 mg PO/BD

4)BP/TEMP/PR/RR monitoring 4th hourly

5) TAB.ultacet 1/2 tab/po/sos