1st December 2022
CHIEF COMPLAINTS :
1) c/o fever since 11 days
2) c/o nausea and vomitings since 6 days
3) burning micturition
patient is very weak and couldnt tell history properly so her history was given by her daughter.
HISTORY OF HER PRESENTING ILLNESS :
Patient was apparently normal 30 years ago then she had an episode of shortness of breath during winter season and it is not associated with cough, sputum, and was subside after taking medication which she follows till this year during every winter season since then.
Then she developed developed neck pain, back ache and bilateral knee joint pain 3- 4years ago for which she is taking ayurvedic medicine and pain killers, monthly 15 to 20 times.
Since the past 1 month she was experiencing generalised weakness and generalised body pains.
Then she developed low grade fever of intermittent type since 10 days associated with nausea and vomiting since 5 days
Her back ache aggrevated since her fever attack and was radiating to the loin.
PAST HISTORY:
HTN was diagnosed 5 DAYS back and she is on TELMIKIND PO OD.
N/K/C/O DM, TB , EPILEPSY
NO H/O PAST SURGERIES
FAMILY HISTORY:
No similar complaints in family
PERSONAL HISTORY:
BUILT : moderate
APPETITE : decreased since 10 days
DIET: mixed
SLEEP : disturbed
BOWEL : regular
BLADDER : decrease and burning micturation.
Daily routine:she wakes up in then morning freshes up takes her breakfast then does some prayers at home then eats lunch then takes some rest and then eats her dinner and goes to her sleep.
DRUG HISTORY :
Use of some unknown medication which helped in relieving her shortness of breath which occurs every winter (Antihistamines??)
Use of painkillers since 3-4 years taking about 15 to 18 tablets for her neck ache , back ache and b/l knee pain
Tablet used is unknown
She also took some ayurvedic medicine along the course during same duration along with with painkillers.
GENERAL EXAMINATION:
She concious, coherent and cooperative
Pallor - present
Icterus-absent
Cyanosis - absent
Clubbing- absent
Genralised lymphadepathy- absent
Pedal edema - none.
Pallor:present
VITALS
TEMP : 98.6 ⁰C
BP : 170/90 mm hg
RR : 20 cpm post extubation
PR : 82 bpm
SYSTEMIC EXAMINATION:
CVS:-
s1 and s2 heard ,no murmurs
RESPIRATORY SYSTEM:-
Central position of trachea
Vesicular breath sounds
BAE+
No abnormal breath sounds,no dyspnea
Abdomen:soft and non tender
INVESTIGATIONS :
ABG:
CUE+serum electrolytes+RBS
USG ABDOMEN :
FINDINGS :-
1) Renal calculi ( 10mm) at right PUJ ( pelvico - ureteric junction )
2) Renal calculi (10mm) at mid pole of right kidney
INTERPRETATION : -
1) Right renal calculi at PUJ causing hydronephrosis of the same kidney.
2) mild hydronephrosis noted in the left kidney.
Input and output
TREATMENT
28/11/22
Inj. Human actrapid Insulin -- > 10 units
29/11/22
Lasix ---> 40mg PO BD
Orofer---> PO OD × 7 days
Shelcal ---> 500 mg PO OD
Paracetamol ---> 650 mg PO SOS
ZOFER ---> 4mg IV stat
30/11/22
Dialysis ( 29/11/22):- during which she experienced a seizure (around 11pm [29th]-12 am[30/11])episode which was controlled by
LEVIPIL ---> 1g IV stat
OPTINEURIN 1g IV stat
Then she was intubated
Given
Inj. ATRACURIUM
Inj. DEXAMETHASONE
Inj. LEVIPIL ---500mg IV TID
Inj. MONOCEF---> 1gm IV BD
Tab LASIX---> 40 mg PO OD
Tab OROFER---> PO OD
Tab SHELCAL---> 500mg PO OD
Tab PCM---> 650mg PO SOS
Inj. OPTINEURIN
Inj. PAN ---> 40 mg IV OD
01/11/22
HD done around 4:30pm
Inj. LEVIPIL ---> 500mg IV TID
Inj. MONOCEF---> 1gm IV BD
Inj. PAN ---> 40 mg IV OD
Inj ZOFER 4ng IV
Tab LASIX---> 40 mg PO OD
Strict I/O charting
Monitor BP,PR, temperature charting four hourly
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