General medicine case

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CHIEF COMPLAINTS:
A 70 year old female patient resident of Aliya who stays at home came to the OPD with chief complaints of:
- Fever since 1 week
 -Right buttock pain since 3  days
-H/o loose stools and vomiting 5 days ago which were subsided. 

HISTORY OF PRESENT ILLNESS:
- patient was apparently asymptomatic  2 years  ago then due  to loss of appetite and generalized weakness patient visited local Hospital and was diagnosed with type 2 diabetes milletus. Since then she was on Oral hyperglycemic agents (unknown).
- 2 months ego patient experienced 1 episode of sudden onset of giddiness and generalized weakness which reduced  in 30 minutes on giving IV fluids.
- she was shifted to TAB. Metformin 500 mg PO/OD
- patient complaints of fever since one week ,high grade ,intermittent with subsided on medication. No chills and Rigor. 
- History of three episodes of vomiting nonbilious,non projectile ,non blood tinged containing food particles for one day.
- History of 3-4 episodes of loose stools, watery for one day which subsided on its own.
- patient visited OPD and was  prescribed antibiotics but her fever did not subside and complained of generalized weakness, loss of appetite and lack of sleep.
- History of right buttock pain since 3 days no history of trauma or any injections taken outside. Pricking type of pain radiating to thighs. 
- No history of decreased urine output, shortness of breath ,chest pain ,pedal edema, cough.

PAST HISTORY :
-No history of HTN, CAD, asthma, tuberculosis.
-know case of DM since 2 yrs. 

PERSONAL HISTORY :
-loss of appetite 
-bowel and bladder-regular
-no addictions
FAMILY HISTORY :
-No significant family history.

GENERAL EXAMINATION :
patient is conscious, coherent, co-operative. 
Temp-afebrile
PR-91 bpm
BP-100/70 mm of Hg
RR-20/min
Spo2-98% at room air
Pallor-present
No icterus, cyanosis,clubbing, lymohadenopathy,edema.

CVS:
S1,S2 heard
No murmurs 
RESPIRATORY SYSTEM :
Bilateral vesicular breath sounds heard
Treachea central
No added sounds
ABDOMEN:
Shape of abdomen -obese
No tenderness, palpable mass, Hernial orifices,free fluid. 
Liver and spleen not palpable 
Bowel sounds heard.
CNS:
Level of consciousness - Alert
Speech-normal
No signs of meningeal irritation. 
Cranial nerves, motor system, sensory system -normal
Reflexes - present 

INVESTIGATIONS:
Chest X-ray :
ECG:
3-8-21
Hb-8.5
Tlc-14,200
Plt-1.5

S. Urea-103
S. Creatinine -3.1
Sodium-131
Potassium -3.5
Chloride-99

9-8-21
Hb-7.7
Tlc-21,800
Plt-3.49

S. Urea-51
S.creatinine-2.4
Sodium-138
Potassium -3.9
Chloride-100
PROVISIONAL DIAGNOSIS :
PRE-RENAL ACUTE KIDNEY INJURY SECONDARY TO ACUTE GE

PLAN OF TREATMENT :
DAY 1
1.IVF-NS,RL@100 ml /hr
2.INJ.CEFTRIAXONE 1GM/IV/BD
3.INJ.PAN 40MG IV/OD
4.INJ.ZOFER 4MG IV/SOS
5.INJ.H.MIXTARD SC/BD
6.INJ.OPTINEURON 1 AMP in 100 ml NS/IV/OD
7.BP/PR/RR/TEMP CHARTING
8.STRICT I/O CHARTING

DAY 2
1.IVF-NS,RL@100 ml /hr
2.INJ.CEFTRIAXONE 1GM/IV/BD
3.INJ.PAN 40MG IV/OD
4.INJ.ZOFER 4MG IV/SOS
5.INJ.H.MIXTARD SC/BD
6.INJ.OPTINEURON 1 AMP in 100 ml NS/IV/OD
7.BP/PR/RR/TEMP CHARTING
8.STRICT I/O CHARTING

DAY 3
1.IVF-NS,RL@100 ml /hr
2.INJ.CEFTRIAXONE 1GM/IV/BD
3.INJ.PAN 40MG IV/OD
4.INJ.ZOFER 4MG IV/SOS
5.INJ.H.MIXTARD SC/BD
6.INJ.OPTINEURON 1 AMP in 100 ml NS/IV/OD
7.TAB.ULTRACET PO/QID/1/2 TAB
8.CHLORHEXIDINE MOUTH WASH/BD
9.TAB.PCM 650 MG PO/BD
10.BP/PR/RR/TEMP CHARTING
11.STRICT I/O CHARTING. 

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