A 26year old Patient came to casuality with shortness of breath

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

A 26 year old male patient, resident of adauidulpally, Nalgonda district farmer by occupation came to our hospital with chief complaints of -

1. Shortness of breath
2. Loss of appetite
3. Low grade Fever 
4. Pedel edema

Date of admission :- 05/04/2022

History of present illness:-
Patient was apparently normal 1week back , then he had one episode of low grade fever, Generalized body pains, burning micturtion but relieved with medication.Then developed pedal edema,initially till ankle
Loss of appetite 
4-5 days back associated with nausea and 
4 days back one episode of vomiting 
Non bilious and no food particles 
No H/o of constipation, No H/o chronic cough present, No H/o of trauma

History of past illness:-
 H/o Rat bite 5 months back 
Not a known case of diabetes, hypertension, tb, epilepsy, asthma 

Personal history:-
Patient has normal eating habit with mixed diet.
Regular alchohol consumption and no smoking.

Daily routine:-
Patient used to wake up at 7.00AM , takes breakfast at 9.00AM .Then he goes to her  work and takes rice in between 4.00PM-5.00PM and dinner at 10.00PM and goes to bed by 11.00PM.

Family history:-
No significant family history.

General examination:-
Patient is conscious, coherent, cooperative and well oriented to time, place and person
No Pallor 
Icterus present
No clubbing
No lymphadenopathy

Vitals:-
Temperature-afebrile
Pulse rate- 90 bpm
RR-24 /min
BP-100/60mmhg
SPO2-97% at room air
ECG
2D ECHO
ULTRA SOUND 
TPR 

Investigations:-
ECG
Ultra sound scan of abdomen
Colour doppler 2D echo

Provisional diagnosis:-
AKI
ALI

Treatment-
 IV fluids 175ml/ her
TAB doxycycline 100mg PO/BD
Inj PAN 40 mg IV/OD
Inj optineuron 1 amp in 100ml NS /IV/OD
TAB PCM 650 mg PO 





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