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



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

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