40 yr female with fever and pedal oedema
40 yr female who is farmer by occupation resident of Masanepelli village,Janagam mandal ,Yadadri district
came with chief complaints of
- Fever since 1 week,subsided 3 days ago
- Pedal oedema since 1 week
-Facial puffiness since 1 week
-Burning micturition 1 week ago ,subsided 3 days ago
-Head ache,neck pain - 1 day
HOPI:
Patient was apparently asymptomatic 1 week ago then she developed fever which was for 3 days which is high grade , intermittent, relieved on medication.Then she developed pedal oedema 3 days ago extending upto knee,pitting type
Past history:
Denovo HTN
N/K/C/O DM, Asthma, TB, Epilepsy, CVA, CAD
Present history:
Appetite -Nornal
Diet-Mixed
Bowel and bladder habits -Burning micturition from 3 days
No Addictions
General Examination:
Patient is conscious, coherent, co-operative,well oriented to time, place and person, moderately built and nourished
No pallor, icterus, cyanosis, clubbing, pedal oedema, lymphadenopathy
Vitals:
PR:99bpm
BP:170/100
RR:25
Temp:98.4F
Systemic Examination:
CVS:S1S2 Present
RS:BAE Present,NVBS
P/A:Soft,non tender
CNS: NAD
Investigations:
Provisional Diagnosis: Fever under evaluation with AKI
Treatment:
1)INJ.PAN 40 MG IV/ OD
2)INJ.LASIX IV/ BD
3)TAB.TELMA PO/ OD