A 70 year old with loin pain
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CASE;
E.Likhitha
8th sem
Roll no.43
A 70 year old female,resident of Erupu village of suryapet district,home maker by occupation came to the hospital with,
C/O,
Loin pain on Right side since 3 years.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 3 years back and then she developed loin pain on right side,pricking type ,which is insidious in onset and gradually progressive .
Then she developed fever from 2 years associated with chills and on medication from 2 years ,it subsides after taking and again regains after sometime.
H/O shortness of breath from 3 years which is of Grade-4 ,breathlessness during resting position
H/O vomitings from 3 months which is of 2 episodes per day and 3 times per week .
Hypertension was diagnosed at the date of admission on (22-12-22).
No H/O low urine output ,burning micturition,pedal edema.
PAST HISTORY:
No similar complaints in the past .
No H/O diabetes ,hypertension,coronary artery disease,seizures and epilepsy.
H/O fall 4 years back for which she underwent a surgery
PERSONAL HISTORY:
Routine history : she wakes up at 6 am in the morning and eats breakfast ,then lunch at 1pm and dinner at 8pm,sleeps at 10-11 pm.She unable do her routine works, so her husband is taking care of her.
Diet-mixed
Appetite-decreased appetite
Sleep-adequate
Bowel and bladder movements -Regular
Addictions - none
FAMILY HISTORY:
No significant family history
DRUG HISTORY:
Tab.Paracetamol since 2 years(2-3 pills per day).
GENERAL EXAMINATION:
Patient was conscious,coherent and cooperative and well-oriented to time ,place,person.Moderately built and nourished.
Pallor present
No icterus
No cyanosis
No clubbing
No generalized lymphadenopathy
No edema
VITALS:
Temperature-febrile
BP:130/80mmHg
RR:20cpm
PR:80bpm
SYSTEMIC EXAMINATION:
Cardiovascular system-S1 and S2 are heard ,no murmurs present.
Respiratory system-Trachea central and normal vesicular breath sounds are heard.
Central nervous system-no neurological deficits
Per abdomen- soft ,non tender ,no organomegaly.
Inspection:
On inspection abdomen is flat, symetrical,and slightly distended.
Umbilcus is centre and inverted
No scars,engorged veins are seen.
All 9 regions of abdomen are equally moving with respiration.
Palpation:
On palpation abdomen is soft and non tender
.On bimanual examination of kidney is not palpable.All inspectory findings are confirmed.
Percussion:no shifting dullness, no fluid thrills
.
Auscultation:normal bowel sounds are heard.
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
CKD with Denovo hypertension with NSAID abuse
TREATMENT:
Fluid restriction
Salt restriction
Inj.LASIX- 40mg IV -TID
Inj.REPOITIN -4000 IV/Weekly once subcutaneously
Tab.SHELCAL- 500mg OD Per orally
Tab.SOBOSIS FORTE -1gm TID Per orally
Tab.Nicardia-10mg per orally
Nebulizer with SALBUTAMOL 6th hourly
Potassium bind sachets in one glass of water per oral TID
Syrup.CREMAFFIN -10ml per oral
Capsule.BIO D3-Per oral OD weakly once
Tab.ULTRACET -1/2 tab QID
Inj.ZOFER-4mg IV TID.
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