GENERAL MEDICINE CASE DISCUSSIONS


65 year old male, farmer by occupation resident of nalgonda, stopped working 6 months ago, in view of generalized weakness,presented to the opd with chief complaints of fever since 5 days(low grade, intermittant and associated with chills). C/O weakness of right upperlimb and left lower limv since 4 days. B/L knee pain. C/O Abdominal distension and facial puffiness ,B/L pedal edema since 4 days. 
No sob, chest pain, palpitations, orthopnea. 
C/O giddiness and loss of appetite.
H/O loose stools 3 days ago(10-12 episodes /day for 2 days, black coloured stools) whhich subsided now associated with pain abdomen in umbilicus. 
No vomitings, headache, cough. No decreased urine output.C/O burning micturition. No h/o trauma,seizures.

PAST HISTORY :
NO H/O DM, HTN, TB, Asthma, CVA, CAD. 
NO H/O previous renal issues. 
H/o covid pneumonia 8 months ago, subsided with in 2 days. 
H/o fall 2 years back on right hand, implant placed. 
H/o typhoid and liver issues which subsided with medication. 

PERSONAL HISTORY :
appetite :lost
Bowel and bladder regular
Sleep decreased 
Addictions:chronic alcoholic 90ml/day
Chronic chutta smoker.

GENERAL EXAMINATION :
patient is c/c/c.
Temp:Afebrile
Bp:70/50 mm Hg
PR:60 bpm
Rr:18 cpm
Spo2:98%at RA
GRBS:104 mg/dl
No pallor, icterus, clubbing,lymphadenopathy,cyanosis.
Edema present. 

SYSTEMIC EXAMINATION :
CVS:S1,S2 heard, no murmurs 
RS :BAE +,NVBS heard. 
P/A:Distended.
No tenderness, palpable masses,bowel sounds heard. 
CNS:
Power             Rt.            Lt
             
          UL.        3/5.          5/5
          LL.          4/5.          3/5

PROVISIONAL DIAGNOSIS :
?AKI on CKD secondary to Acute GE
Fever with thrombocytopenia with bleeding manifestations with unilateral monoparesis(LMN type).

LEFT UPPER LIMB POP EYE MUSCLE


IMPLANT IN THE RIGHT UPPER LIMB



INVESTIGATIONS:
HB:11g/dl
TLC: 10,700
PLT: 81000
ESR :7mm/hr

S. CREAT:8.8
URIC ACID:7.8
TB:1.3

Na :135
K :2.6
Cl :98

Ns1  antigen :negative 
22-9-21:

23-9-21:


24-9-21:

PLAN OF CARE:
IVF:NS,RL @ 50 ml/ hr
Inj. Pan 40mg iv/OD
Inj. Piptaz 4.5g/iv/stat--->2.25g iv/qid
Inj. Lasix 40mg iv/bd
Tab. Pcm 650 mg po/sos
Tab. Doxy 100mg po/bd
Tab. Nodosis 500mg po / tid
Tab. Shelcal 500mg po/OD
INJ. Optineuron 1 amp. in 100 ml NS IV /OD


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