Chief complaints :
1.shortness of breath since 2 days
2.1 episode of fever 2 days ago.
3.excessive sweating on day of admission.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 4 days ago she then developed fever which was intermittent associated with generalised weakness and was taken to hospital. There she received medications, her fever was subsided. Later that night her BP was low and she complained of abdominal discomfort and had an episode of loose stools, watery consistency 4 episodes.
Fever was intermittent associated with sweating and generalised weakness, not associated with chills and rigor.
Abdominal discomfort is not associated with abdominal pain, nausea, vomiting.
Shortness of breath was not associated with cough, cold, chest pain.
No h/o dizziness, pallor, orthostatic hypotension, blood loss.
No H/o burning micturition, reduced urinary output
No H/o palpitations, chest pain.
No H/o headache, dizziness, episodes of Syncope.
PAST HISTORY:
No h/o of DM, HTN, EPILEPSY, asthma, TB.
PERSONAL HISTORY:
Appetite normal
4 episodes of loose stools
No addictions
No known allergies
Diet nonveg
Sleep adequate.
Family history:no significant family history
Menstrual history: menopause attained.
General examination :
Patient is conscious coherent and cooperative, well oriented to time place and person and was examined in a well light room after taking consent.
No signs of pallor, icterus, cyanosis, clubbing, lumphadenopathy.
B/L pitting type of pedal edema extending till ankles.
B/L swelling of both arms extending till wrist. Pitting type of edema.
VITALS
1.on day of admission
PULSE 110 beats per min.
B. P. 90/60 mmhg
R. R. 26cpm
GRBS 96mg/dl.
SYSTEMIC EXAMINATION :
Respiratory system:
INSPECTION :
Trachea appears to be central
Shape is elliptical
Symmetrical movement with respiration
Palpation
Three finger test-central trachea
Equal movements with respiration
No local rise of temperature.
Percussion
B/L dullness noted in the inframammary, infra axillary and infra scapular areas
Auscultation
B/L crepitations noted in the infra axillary and infrascapular areas.
Abdominal examination:
Shape of the abdomen is obese
Moves with respiration
Umbilicus is inverted
No visible scars, sinuses. No distended veins.
On Palpation
No localised rise of temperature
Liver is not palpable
Spleen is not palpable
No localised Tenderness.
On percussion
Liver span is 9 cm.
Shifting dullness is not present
Fluid thrill is not present
Bowel sounds were heard.
CVS EXAMINATION :
apex beat is heard in 5th ICS 1cm lateral to mid clavicular line.
No visible JVP pulsations.
S1 S2 heard no murmurs.
URINARY OUTPUT:
LOW urinary output was noted on day of admission.
PROVISIONAL DIAGNOSIS: Acute lung injury and acute kidney injury secondary to shock.
Lab reports :
On 14th june
On 15th June 2023.
Diagnosis: SPECTIC SHOCK
METABOLIC ACIDOSIS
AKI.
Prognosis of the patient.
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