04 venkat sai (29/06/22)
GENERAL MEDICINE CASE (28-06-22)
DATE OF ADMISSION - 23/06/22
CHIEF COMPLAINTS
-45yr old female came to OPD with chief complaints of vomitings ,nausea and epigastric burning sensation.
HISTORYOF PRESENT ILLNESS
-Pt was apparently normal 4yrs back then she developed burning micturition, pedal edema, right loin pain for which she visited local hospital.
-she diagnosed with rght renal caliculus with pyelonephritis then referred to nims and there she went rght nephroctomy.
-since 10 -15 days she has been suffering with nausea,vomitings and epigastric discomfort.
- 4 to 5 episodes of vomitings with small quantity of food particles as it’s contents.
-No blood in vomitings.
HISTORY OF PAST ILLNESS
-Right nephrectomy in 2018
TREATMENT HISTORY
Not a k/c/o DM,HTN
Not a k/c/o CAD,TB,asthma,chemo,radiation and blood transfusion.
PERSONAL HISTORY
Mixed diet
Appetite Lost
Sleep adequate
Bowel movements regular.
Micturition abnormal.
FAMILY HISTORY
Not significant
PHYSICAL EXAMINATION
Temp- afebrile
BP-130/80 mm hg
Pulse rate-82/min
Respiratory rate-16/min
Spo2-98%
-No signs of pallor,cyanosis,lymphadenopathy,icterus.
-Oedema present
SYSTEMIC EXAMINATION
•S1, S2 heard
•No murmurs
RESPIRATORY SYSTEM:
•NVBS heard
•Position of trachea - central
•Breath sounds - vesicular
ABDOMEN
•Shape - scaphoid
•No Tenderness
•No palpable mass
-No fluid present.
-No palpable liver or spleen
CENTRAL NERVOUS SYSTEM:
•Intact
•No focal defect
•No abnormality detected
CEREBRAL SIGNS
• No finger nose incordination
•No knee heel incordination.
INVESTIGATIONS
PROVISIONAL DIAGNOSIS
Acute kidney injury
