A 60 year old male with fever and pedal edema

This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.

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

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 murmus
 
RS: NVBS 



CNS: Hmf intact,no focal neurological deficits 

per abdomen:soft,nontender,no organomegaly

DIAGNOSIS: ACUTE KIDNEY INJURY


INVESTIGATIONS:

USG
DOPPLER


on 21/3/23
on 21/3/23


on 22/3/23






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

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