42years old male patient with chief complaint of fever, vomiting,SOB

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Date of admission:11-10-2022

Date of discharge:13-10-2022

Chief Complaints:

42years old male patient with chief complaint of fever since 6days, vomiting since 4days SOB since 2days

History of Present Illness:

Patient is apparently asymptomatic 6days back then he developed fever which is insidious in onset gradually progressive with vomitings which is non bilious non projectile non blood stain with food as content

yellowish discoloration of body and urine

Decreased urine output 

SOB since 2days

History of Past illness:

No h/o of Diabetes mellitus and hypertension 

asthma,tb,CAD,epilepsy,lymphadenopathy, surgery

Personal History:

Married

Diet-mixed

Appetite-normal

Bowel movement-Regular

Micturition-normal

Addictions- No

Family History:

 No history of DM, CAD, Asthma and thyroid disorders in the family

General Examination:

Vitals:

Temp:98.2°f

Respiratory rate:18bpm

Pulse:102bpm

Blood pressure:120/80mmhg

Sp O2 97

Systemic Examination:

Cardiovascular system

Thrills:no

Cardiac sounds:S1,s2 sounds

Cardiac murmurs:no

Respiratory system:

Dysponea : No

Wheeze: No

Position of trachea:Central

Breath sounds: vesicular

Adventitious sounds:no

Abdomen

Shape of abdomen:scaphoid

Tenderness:no

Palpable mass:no

Henias orifices: normal

Free fluid:no

Bruits:no

 

Liver: Not palpable

Spleen: Not palpable

Bowel sounds:yes

Central Nervous system:

 Pt is conscious

Speech: Normal

Signs of meningitis:No signs

Cranial nerves: Normal

Motor and sensory system: Normal

Provisional Diagnosis:

CKD on MHD

Investigation:

Treatment: