General Medicine case 6
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Date of admission:9/03/2022
Chief complaint:
A 24 year old male who is cattle by occupation came to odp with chief complaints of :
Decreased urine since 10 days
SOB since 10 days
Pedal edema since 10 days
Fever since 10 days
History of present illness:
Patient was apparently asymptomatic 3 years back. Then he developed decreased urine output for which he went to local hospital and scan was done which revealed hydronephrosis.
Ten days back he had a trauma to the left little finger and dorsum of right foot for which he went to local hospital and dressing was done .
10 days back he developed shortness of breath which was insidious in onset and gradually progressive aggravated on walking relieved on medication .
Pedal edema since 10 days which was extending till ankle.
Fever since 10 days which was continous not associated with chills.
Past history:
No K/c/o DM , HTN , asthma , epilepsy , BA ,TB, CAD.
No past surgical history.
BP-130/80 mm hg
PR -88bpm regular
Cvs- s1 s2 +
Rs - BAE +
P/A-soft , non tender
Treatment:
1.Inj piptaz 4.5 gm IV STAT F/B inj . Piptaz 2.25 gm IV / QID
2.inj clindamycin 600 mg /IV / tid
3.inj pan 40 mg IV /od
4.Tab nodosis 500 mg po/bd
5.Tab shellac 550 mg po / od
6.IVF NS and RL @ 100 ml / hr
7.Inj lasix 40 mg IV / bd if bp is more than 110 mm of hg
8.Tab alpha - D3
Provisional Diagnosis:
Chronic kidney disease with
Hydroureteronephrosis.
Clinical Images:
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