A 26year old Patient came to casuality with shortness of breath

 

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A 26 year old male patient, resident of adauidulpally, Nalgonda district farmer by occupation came to our hospital with chief complaints of -

1. Shortness of breath

2. Loss of appetite

3. Low grade Fever 

4. Pedel edema

Date of admission :- 05/04/2022

History of present illness:-

Patient was apparently normal 1week back , then he had one episode of low grade fever, Generalized body pains, burning micturtion but relieved with medication.Then developed pedal edema,initially till ankle

Loss of appetite 

4-5 days back associated with nausea and 

4 days back one episode of vomiting 

Non bilious and no food particles 

No H/o of constipation, No H/o chronic cough present, No H/o of trauma

History of past illness:-

 H/o Rat bite 5 months back 

Not a known case of diabetes, hypertension, tb, epilepsy, asthma 

Personal history:-

Patient has normal eating habit with mixed diet.

Regular alchohol consumption and no smoking.

Daily routine:-

Patient used to wake up at 7.00AM , takes breakfast at 9.00AM .Then he goes to her  work and takes rice in between 4.00PM-5.00PM and dinner at 10.00PM and goes to bed by 11.00PM.

Family history:-

No significant family history.

General examination:-

Patient is conscious, coherent, cooperative and well oriented to time, place and person

No Pallor 

Icterus present

No clubbing

No lymphadenopathy

Vitals:-

Temperature-afebrile

Pulse rate- 90 bpm

RR-24 /min

BP-100/60mmhg

SPO2-97% at room air

ECG

2D ECHO

ULTRA SOUND 

TPR 

Investigations:-

ECG

Ultra sound scan of abdomen

Colour doppler 2D echo

Provisional diagnosis:-

AKI

ALI

Treatment-

 IV fluids 175ml/ her

TAB doxycycline 100mg PO/BD

Inj PAN 40 mg IV/OD

Inj optineuron 1 amp in 100ml NS /IV/OD