General medicine

Ch Janani
Roll no. 29

A female patient aged 74 yrs  came to the OPD with chief complaints of fever  ,shortness of breath ,and she had altered sensorium.

Chief complaints
Fever ( 7 days)
Shortness of breath(4 days )
Altered sensorium ( 2-3 days)

History of present illness
Patient was apparently asymptomatic 10 days back and
She was admitted to hospital by her family due to loss of consciousness,fever,loss of speech and altered sensorium.

History of past illness

N/k/c/o diabetes mellitus,CAD and CVA hypertension,TB, epilepsy,no previous surgeries.
She is a known case of asthma using inhalers ( duration not known)

Personal history
She is married
Diet : mixed
Bowel and bladder movements: normal 
Appetite: normal
No allergies
No addictions
Drug history: used pain killers for pain and swelling of lower limbs

General examination 
Palor
No cyanosis
No icterus
No clubbing of fingers
Pedal edema present ( pitting type ) 
Moderately built
No Lymphadenopathy

Vitals 
Temperature: afebrile
Pulse rate: 107/ min
Respiratory rate : 26/ min
BP : 180/80 mmHg


Systemic examination
Cvs 
S1 and S2 are heard
No thrills 
No cardiac murmurs

Respiratory system
No dyspnea
Wheezing present - diffuse
Position of trachea is central
Breath sounds vesicular

Abdomen
Shape : obese
No tenderness
No palpable mass
No hepatomegaly and splenomegaly

CNS 
The level of consciousness is drowsy and arousable 
Speech : no response
Cranial nerves ,motor and sensory system are normal

Provisional diagnosis 
AKI on CKD secondary to Bronchiectasis/ sepsis with uremic encephalopathy.

Investigations





Treatment
Inj PIPTAZ 4.5 g
Add inj PIPTAZ 0.75 mg
Inj ZOFEX 4 MG 
TAB NODOSIS 500 mg
TAB OROFER ×5/PO/OD
TAB SHELCAL 500 mg / PO/OD






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