A 62 year old female, homemaker by occupation, came to the casualty with chief c/o fever since morning a/w b/l loin pain since 4 days, burning micturition and SOB (Grade 4). She also c/o neck pain and low back ache since 4 days.
HISTORY OF PRESENT ILLNESS : Patient was apparently asymptomatic 2 years ago and then developed bilateral loin pain not a/w pedal edema or facial puffiness. It was diagnosed to be CKD for which she has been taking medication. The patient developed burning micturition, b/L loin pain, low back ache and neck pain (restriction of movement +) since 4 days. She had fever since morning which was relieved on medication and was not a/w chills and rigor. Patient also c/o SOB (Grade 4). No complaints of Orthopnea, PND, pedal edema, chest pain, palpitations.
PAST HISTORY :
No h/o HTN, DM, Epilepsy, CAD, TB.
Patient is a k/c/o CKD since 2 years and is on conservative treatment.
FAMILY HISTORY : NAD
PERSONAL HISTORY :
Diet - Mixed
Appetite - Normal
Bowel - Regular
Bladder - Decreased
Sleep - Adequate
Addictions - None
GENERAL EXAMINATION :
No Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Pedal edema.
VITALS :
PR - 90 bpm
BP - 130/80 mm Hg
RR - 23 cpm
SpO2 - 98%
GRBS - 110mg/dl
SYSTEMIC EXAMINATION :
CVS - S1, S2 heard, No thrills, No murmurs
Respiratory - Trachea position : central, NVBS heard, BAE +
P/A - Soft, non tender, bowel sounds heard, Liver and spleen not palpable
CNS - Conscious, Speech:normal, no signs of meningeal irritation, motor and sensory system normal, reflexes present
2-07-2021
INVESTIGATIONS-
ABG
CUE
HEMOGRAM
RBS
BLOOD UREA
SERUM CREATININE
LFT
URINARY ELECTROLYTES
URINE PROTEIN / CREATININE RATIO
ECG
USG
RT-PCR
4-07-2021
HEMOGRAM
CBP
RFT
