50 year old female with fever and bilateral pedal edema
SAI DHEERAJ
Blood grouping
Serum creatinine -time : 1:59 am
Serum electrolytes - time : 1:56 am
CHEST X RAY
Blood urea
Serum electrolytes
On day 4 (23-8-22)
Serum creatinine
Blood urea
Blood urea
Serum electrolytes
Liver function tests
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A 50-year-old female patient came to the casualty with the cheif complaints of fever and swelling of both the legs since 3 days.
History of present illness :
H/o Fever-
Onset - insidious
Duration- since 4 days
Type - intermittant
Associated with chills and rigors.
Diurnal variation present
Increased temperature at night
H/0 constipation for 2 years
Passes stools once every 3 days
H/0 loose stools 4 days back
6 episodes
Non-blood stained
Mucus is present.
H/o of association of pain in lower limbs from thighs to toe everytime she moves her legs since 5 days
Onset- insidious
Duration- 5 days
Type - dragging type
No diurnal variation
Aggravating factors- on walking and while going to bathroom
Relieving factors- on rest
H/o vomiting on 20-8-22 back associated with nausea.
4 episodes , everytime she consumes food.
Contents- food
Bilateral pedal edema since 3 days
Pitting type
Burning micturition present
No history of shortness of breath
4 days back, she went to local area hospital in suryapet and got her reports done which showed,
1. Low platelet count
2. High creatinine and bilirubin
History of past illness :
Not a known case of,
Hypertension, diabetes, epilepsy, CAD, asthma, thyroid.
Personal history :
Diet - mixed
Appetite - normal
sleep - adequate
Bowel and Bladder movements - regular
Addictions - no
No known allergies
Drug history :
No significant drug history
Family history :
No significant family history
General examination :
Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person
at the time of examination
SHe is examined in a well lit room, with consent taken.
SHe is moderately built and well nourished.
Pallor - present
Icterus - present
Cyanosis - absent
Clubbing - absent
lymphadenopathy - absent
Pedal edema - present
Vitals :
Temperature - Afebrile
Pulse rate - 96 bpm
Respiratory rate - 16 cpm
Blood pressure - 120/70 mmHg
SpO2 - 98% on Room air
GRBS - 101 mg/dl
Systemic examination :
CVS : S1 and S2 heart sounds heard
NO murmurs and thrills
RESPIRATORY SYSTEM : Bilateral air entry present, position of trachea - centrall
Vesicular breathsounds heard
CNS : intact
ABDOMEN : Soft and non tender
No palpable masses
Bowel sounds heard
NO organomegaly
Investigations :
On 20-8-22 at suryapet hospital
On the day of admission (20-8-22)
Dengue NS1 antigen , IgG and IgM rapid test:
On day 2 (21-8-22)
Hemogram
Urine protein and creatinine ratio:
Blood sugar - random
Blood urea - time: 1:59 am
time: 3:58 am
Blood urea -147 mg/dl
Complete urine exmination
- time : 3:58 pm
ECG
Ultrasound abdomen
On day 3 ( 22-8-22)
Hemogram
Blood urea
Serum creatinine
Serum electrolytes
Hemogram
Liver function tests
Serum electrolytes
Malarial parasite
On day 5 (24-8-22)
APTT
PT
Hemogram
Serum creatinine
ESR
C- reactive protein
Serum electrolytes
On day 6 (25-8-22)
Hemogram
Serum creatinine
Blood urea
Treatment:
On 20-8-22
1.IVF - ns, RL @75ml/hr
2.Tab. Pan 40mg PO/OD
3.Tab. Zofer 4mg PO/ BD
4.Tab. paracetamol 650mg PO/TID
5.INJ. Neomol IV / SOS if temp >102°
6Temperature monitoring 4th hourly
7.Strict vitals monitoring - BP,PR 2nd hourly
On 21-8-22
1.IVF - 1 unit ns, RL @75ml/hr
2.Tab. Pan 40mg IV OD BBF
3.Tab. Zofer 4mg IV SOS
4.Tab. DOLO 650mg PO SOS
5.INJ. Neomol 1gm IV / SOS if temp >102°
6.INJ. Lasix 20mg IV BD at 8 am ,4 pm
7.Temperature charting ,RR,BP,PR 8th hourly
On 22-8-22
1.IVF - 1 unit ns, RL @75ml/hr
2.Tab. Pan 40mg IV OD BBF
3.Tab. Zofer 4mg IV SOS
4.Tab. DOLO 650mg PO SOS
5.INJ. Neomol 1gm IV / SOS if temp >102°
6.INJ. Lasix 20mg IV BD at 8 am ,4 pm
7.Temperature charting ,RR,BP,PR 8th hourly
On 23-8-22
1.IVF - 1 unit ns, RL @75ml/hr
2.Tab. Pan 40mg IV OD BBF
3.Tab. Zofer 4mg IV SOS
4.Tab. DOLO 650mg PO SOS
5.INJ. Neomol 1gm IV / SOS if temp >102°
6.T. Doxy 100mg PO BD
7.Temperature charting ,RR,BP,PR 8th hourly
On 24-8-22
1.IVF-1×NS,RL @75 ml/hr
2.INJ.ZOFER 4 mg IV/SOS
3.INJ.NEOMOL 1GM/IV / SOS if temp >101°F
4.T DOXY 100mg PO BD
5.TAB.DOLO 650 mg/PO/SOS
6.BP,PR,RR,TEMP CHARTING 6TH HOURLY
7.SYP cremafin sulfate PO HS 15ml
2.INJ.ZOFER 4 mg IV/SOS
3.INJ.NEOMOL 1GM/IV / SOS if temp >101°F
4.T DOXY 100mg PO BD
5.TAB.DOLO 650 mg/PO/SOS
6.BP,PR,RR,TEMP CHARTING 6TH HOURLY
7.SYP cremafin sulfate PO HS 15ml
On 25-8-22
1.IVF-1×NS,RL @75 ml/hr
2.INJ.ZOFER 4 mg IV/SOS
3.INJ.NEOMOL 1GM/IV / SOS if temp >101°F
4.T DOXY 100mg PO BD
5.TAB.DOLO 650 mg/PO/SOS
6.BP,PR,RR,TEMP CHARTING 6TH HOURLY
7.SYP cremafin sulfate PO/OD/ HS 15ml
2.INJ.ZOFER 4 mg IV/SOS
3.INJ.NEOMOL 1GM/IV / SOS if temp >101°F
4.T DOXY 100mg PO BD
5.TAB.DOLO 650 mg/PO/SOS
6.BP,PR,RR,TEMP CHARTING 6TH HOURLY
7.SYP cremafin sulfate PO/OD/ HS 15ml
Provisional diagnosis: AKI secondary to leptospirosis
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