70 year female with sob

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Chief complaints:

Shortness of breath grade 4, from 10 days ,fever from 10 days,loss of appetite from 6 days ,burning micturition from 4 days,decrease urine output s from 4 days.

History of presenting illness:

Patient was apperantly asymptomatic 10 days back then she had SOB grade 4 and fever which is intermittent associated with rigors and chills and relieved on medication.

Patient was taken to hospital 8 days back and diagnosed as typhioid and was treated for the same.

Patient c/o of burning micturition and decreased urine output 4 days back

 History of past illness:

K/c/o dm from 15 years (treatment with metformin 500mg)

K/c/o HTN from 10 years (treatment with telmisartan 40/12.5mg)

N/k/c/o of TB,cad, epilepsy,asthma

Daily routine:

She wakes up at 5 am 

She does her breakfast at 8 to9 am.daily roti.

She does her household work .

She has lunch at 1.30 pm roti or rice .

She takes rest ,

She takes her dinner around 8 pm .

She sleeps daily at 9 pm.

Family history:

No significant family history.

Personal history:

Appetite normal.

Mixed diet.

Regular bladder and bowel movements.

No allergies .

Addictions:

Alcohol taken occasionally

Tobacco smoking daily 3 times since childhood.

General examination:

Patient is c/c/c well oriented to time and place .

BP:110/80mm hg.

PR:98bpm

RR:16cpm

No pallor/icterus /cyanosis/clubbing/lymphadenopathy/

Pedal odema present which is pitting type

Abdominal swelling also present .

Systemic examination:

Cvs:S1,s2heard.

No thrills and cardiac murmurs

Respiratory system;

Dyspnea:present

No wheezing

Position of trachea central

Breath sounds vescicular

BAE +ve

Per abdomen :

Soft ,non tender,swollen

No palpable mass 

Liver and spleen not palpable.

Investigations:

Provisional diagnosis:

AkI on CKD.

Treatment:

Inj .piptaz 2.25 mg iv/tid

Inj neomal 1 mg iv/sos(if temp >101°F)

Tab lasix 40 mg po/bd

Tab nodosis 500 mg po

Tab orofer -xt po/od

Tab shelcal 500 mg po /od

Tab pcm 500 mg po/sos

Capsule bio D3 po/ weekly twice