55 year old with h/o Anuria(since 1 day ) and fever since 4 days
Chief complaints -
A 55 year old female presented to casualty with c/o of anuria since yesterday night
HOPI-
PATIENT was apparently asymptotic 1 year ago , when her sister died she cried a lot , felt weak and was taken hospital , routine investigations were done and was told she had kidney problem and was referred to kamineni I/v/o dialysis and was admitted for 2 sessions of dialysis .Urology opinion was taken for ?obstructive uropathy , ?kidney operation was done ,used medication for 3 months and the symptoms were relieved
H/o nsaid use for 1year h/o pedal edema and facial puffiness 6 months ago .
Sob not present
Comorbities - hypertensive since 6 months
Headache (frontal since 2 months )
H/o fever since 4 days associated with chills
H/o anuria since 1 day
H/o vomitings 1 episode (non projectile,non bilious ),food as contents
No h/o hematuria , frothy urine
No h/o cold , cough , loose stools , burning micturition
Family history
Not significant
Personal history
Occupation -farmer
Daily routine -work in the morning , takes staple food as breakfast , at 1 pm she eats lunch (rice)
Diet -mixed
Appetite -normal
Sleep -adequate
Bowel habits -regular
Addictions -h/o toddy intake since 15 years
General examination
Patient is c/c/c
Bilateral pedal edema +
NO icterus ,cyanosis , clubbing , lymphadenopathy
Pallor +
Temp -100 degree f
BP -140/90 mmhg
PR -92 BPM
SPO2 -98 %@RA
RR -18 CPM
Systemic examination
CVS - s1 s2 + , no added murmurs
Rs - nvbs +
P/a -soft , non tender , no organomegaly , bowel sounds +
CNS - no focal neurological deficits present
INVESTIGATIONS -
TREATMENT GIVEN
1.IVF NS AND RL 30 ML /HR URINE OUTPUT +
2.INJ.PANTOP 40 MG/IV/OD
3.INJ.ZOFER 4 MG/IV/BD
4.INJ.LASIX 40 MG/IV/BD
5.TAB.NODOSIS 550 MG/PO/BD
6.TAB.SHELCAL 50P MG/PO
7.TAB OROFER /PO/OD
8.STRICT I/O CHARTING
9.TAB.PCM 680 MG/PO/SOS
10.INJ.NEOMAL 1 GM/IV IF TEMP > 101.1 F
11.MONITOR VITALS hourly
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