41F with Facial puffiness and B/L pedal edema since 1week
Case History and Clinical Findings
MODERATRE TR WITH PAH,MILD MR,TRIVIAL AR,NOI AS/MS GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION USG ABDOMEN: MILD ASCITIS
40yr F came with chief complaints of- Fever since 1 week,subsided 3 days ago- Pedal oedema since 1 week-Facial puffiness since 1 week-Burning micturition 1 week ago ,subsided 3 days ago-Head ache,neck pain - 1 day
HOPI:Patient was apparently asymptomatic 1 week ago then she developed fever which was for 3 days which is high grade , intermittent, relieved on medication.Then she developed pedal oedema 3 days ago extending upto knee,pitting type
Past history:Denovo HTNN/K/C/O DM, Asthma, TB, Epilepsy, CVA, CAD
Personal history:Appetite -NornalDiet-MixedBowel and bladder habits -Burning micturition from 3 daysNo Addictions
General Examination:Patient is conscious, coherent, co-operative,well oriented to time, place and person, moderately built and nourishedNo pallor, icterus, cyanosis, clubbing, pedal oedema, lymphadenopathy
Vitals:
PR:99bpm
BP:170/100
RR:25
Temp:98.4F
Systemic Examination:
CVS:S1S2 Present
RS:BAE Present,NVBS
P/A:Soft,non tender
CNS: NAD
2D ECHO :
NO RWMA ,MILD LVH EF 60%
IVC SIZE 1.55CMS
MODERATRE TR WITH PAH,MILD MR,TRIVIAL AR,NOI AS/MS GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION
USG ABDOMEN: MILD ASCITIS.
MODERATRE TR WITH PAH,MILD MR,TRIVIAL AR,NOI AS/MS GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION USG ABDOMEN: MILD ASCITIS
B urea 70mg/dl
Diagnosis AKI WITH UNDIFFERENTIATED FEVER DENOVO HTN
Treatment Given(Enter only Generic Name) 1)INJ.CEFTRIAXONE 1 GM IV/BD 2)TAB DOXY 100MG PO BD 3)TAB TELMA 40MG PO OD 4)INJ.LASIX 20MG IV/BD 5)T.CINOD 10MG PO/OD 6)INJ.PAN 40MG IV OD
Advice at Discharge
1)T.LASIX 20MG PO/BD 8AM-4PM X5DAYS 2)T.CINOD-T PO/OD 3)T.MVT PO/OD X 10 DAYS 4)SALT RESTRICTED DIET
