50YR FEMALE WITH AKI
50 year old female patient agriculture worker by occupation resident of nalgonda came to casuality with Cheif complaints of fever since 7 days , vomitings since 3 days and decreased urine output since 2 days
History of present illness:- patient was apprently asymptomatic 10 years back then she developed prolapse of uterus during delivery and was suggested for the surgery but the patient refused which progressed to the current shape and size
H/o pulmonary kochs 10 years back used ATT for 3 months
Complaints of fever since 7 days which is low grade and associated with chills and reelived on using medication
Vomiting since 3 days , non projectile and not blood tinged and food as content
Complaints of cough with sputum white in color and is associated with shortness of breath which is subsided now
Complaints of burning micturation since 3 days associated with decreased urine output and not associated with hesitency , urgency , increased frequency
Also complaints of pain in abdomen since 7 days and aggravated when uterus prolapses and pain is dragging type increased since 1 year
Past history :- N/K/C/O DM , HTN , CVA , CVD
Personal history:-
Diet :- mixed
Appetite :- normal
Bowel and bladder movements :- regular
Sleep :- adequate
General examination:- patient is conscious, coherent, cooperative.
Vitals at presentation :-
Bp:- 110/60mmhg
Pr:- 78bpm
Rr :- 19cpm
Spo2 :- 98%
Temp:- 97.8
No pallor , icterus , cyanosis , clubbing, lymphadenopathy
Sytemic examination:-
Cvs :- s1 s2 heard
Rs :- decreased breath sounds in left IAA crepts heard at left ISA
P/A :- soft non tender
Investigations :-
Necessary investigations were done
Ecg :-
Hrct chest :-
Chest xray :-
Referals :-
Provisional Diagnosis :-
1. Viral pyrexia under evaluation
2 acute kidmey injury non oliguric ?renal? Post renal
3 uterovaginal prolapse (3 degree)
4 left upper lobe large bulla communicating with left upper lobe bronchus
5 bilateral mild pleural effusion (rt>lft)
6 H/o pulmonary kochs (drug defaulters 10 years back)
Plan of care:-
1 IV FLUIDS NS ( urine output plus 30ml/hr)
2 INJ LASIXS 20mg IV BD
3 TAB PANTOP 40mg sos
4 TAB DOLO 650mg PO SOS
5 SYP ASCORIL LS 10ml PO TID
6 INJ MONOCEF 1gm IV BD
7 TAB ALDACTONE 25mg PO OD
8 DAILY VAGINAL PACKING BD
9 STRICT I/O CHARTING
10 VITALS MONITORING 6th hourly
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