65 F with AKI on CKD, Gastroenteritis,
Patient came with complaints of fever since 1 week, burning micturition since 5 days, generalized weakness since 5 days, loose stools and vomitings since 2 days.
Patient was apparently asymptomatic 1 week ago then developed fever, high grade, associated with chills and rigor, relieved on medication, no diurnal variation.
Burning micturition since 5 days, generalized weakness since 5 days, vomitings since 2 days, 3-4 episodes per day, non bilious, non projectile, non bloodstained, content is food particles. Loose stools since 2 days, watery, small volume non blood tinged.Loss of Appetite +
H/o Multiple joint pains, LBA, knee pains, took nsaids outside.
H/o on and off fever since 1 month,
K/C/O CKD since 3 months on medication,
K/C/O Hypertension since 5 years on regular medication.
Swelling over left eyebrow due to fall from bed 1 week ago.
Foley’s was inserted
Pedal edema absent
Pallor -absent
PERSONAL HISTORY
APPETITE : LOST
DIET: MIXED
BOWELS AND BLADDER: REGULAR
NO ADDICTIONS
GENERAL EXAMINATION:
PATIENT IS C/C/C
PALLOR+ ,ICTERUS, CYANOSIS, LYMPHADENOPATHY,EDEMA.
TEMP: 99.4 F
PR:116
RR: 24
BP: 130/80
SPO2 98 AT ROOM AIR
GRBS: 122 mg/dl
SYSTEMIC EXAMINATION
CVS :
S1 S2 Heard
RS: BAE +
CNS: No FND
GCS: E4 V5 M6
GI: P/A SOFT NON TENDER NO ORGANOMEGALY
Investigations:
Treatment
Comments
Post a Comment