A 65 old female came with chief complaints of decreased appetite since 10 days

 A 65 year old female came with chief complaints of decreased appetite,fever , generalised weakness and irregular bowel and bladder since 10 days.

HOPI 

Patient was apparently asymptomatic 5 yrs back.

Then she was diagnosed with diabetes mellitus and hypertension when she went to the hospital for the general check up.

She is on medication for HTN and stopped using medication for DM since year because of the low sugar levels

Then 1 year ago she developed swelling of legs for which she  went to the hospital and she was told the kidney is shrunken and she has infection in the kidney.she used mediation for this problem.

Now since 10 days her appetite was decreased and she also had fever which was high grade and more during the night time and associated with chills and rigor.

She also had history of vomiting since 10 days like 1 episode per day 

Bowel and bladder was irregular but since 2 days it became regular because she took a tablet.

Her daughter  complained of weight loss also

Patient s daily routine

Patient was a agricultural labourer but stopped working since 1 year because of weakness.Now she gets up in the morning and does some personal work and leading a sedentary life.

PAST HISTORY

No similar complaints in the past

History of DM and HTN since 5 years.No history of TB, Asthma, Epilepsy 

Treatment history:Telmisartan for HTN

PERSONAL HISTORY

Diet Mixed

Appetite decreased

Bowel and bladder regular

Sleep adequate

No addictions 

FAMILY HISTORY

No significant family history 

GENERAL EXAMINATION 

Patient was conscious coherent and uncooperative

Moderately built and nourished

Pallor: present

Icterus absent

Cyanosis absent

Clubbing absent

Generalised lymphadenopathy absent

Edema absent 

Vitals 

Temperature Afebrile

RR 19 cpm

PR 74 bpm 

BP 140/90 mm Hg 

Systemic examination

Respiratory system BAE present , normal vesicular breath sounds heard

CVS s1,s2 heard, no murmurs

GIT soft and non tender

CNS No focal neurological deficit 






INVESTIGATIONS 





















RFT 

Urea 96 mg/dl 

Creatinine 2.3 mg/dl 

CBP 

Haemoglobin 6.3 

PCV 18.3 

RBC 2.3 million/mm³

Provisional diagnosis 



TREATMENT

Inj Neomol 100 ml/IV/

Inj PAN 40 mg/IV/OD 

Inj Zofer 4g Iv(SOS)

Inj OPTINEURON 1 amp in 100 ml NS/IV/OD 

Tab ECOSPIRIN AV (75/20) po/Hs






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