50 year old female with fever, vomiting, burning micturition,SOB

A 50yrs old female c/o fever, vomiting, burning micturition,SOB

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Chief Complaints:

C/O Fever since 10days, Burning micturition since 10days, vomitings since 10days (5-6 episodes),Grade 3 SOB since 10days

History of Present Illness:

Patient is apparently asymptomatic 10days back then she noticed fever low grade,continuous type not associated with chills and rigors

H/o vomiting non projectile,non bilious,food as content

C/o SOB Grade 3 since 3days

C/o burning micturition after foleys insertion at local hospital

History of Past illness:

H/o hypertension since 2months (on regular medication)

No h/o DM,Asthma, epilepsy,TB,CAD

Personal History:

Married

Occupation: daily wage labour

Diet:mixed

Appetite:normal

Bowel movements: regular

No drug allergy

Family History:

No h/o DM, Asthma, Hypertension,TB,CAD, Epilepsy in the family

Menstrual history:

Menopause:20years back

General Examination:

Vitals:

Temp: Afibrile

Respiratory rate:24bpm

Pulse:86bpm

Blood pressure:130/90mmhg

Sp O2:96

Systemic Examination:

Cardiovascular Examination:

Thrills:No

Cardiac sounds:S1,S2 sounds 

Cardiac murmurs:No

Respiratory system:

Position of trachea:central

Breath sounds: vesicular

Adventitious sounds:no

Wheeze:no

Dysponea:no

Abdomen

Shape of abdomen: scaphoid

Tenderness:not tender

Palpable mass:no

Henias orifices: normal

Free fluid:no

Bruits:yes

 

Liver:not palpable

Spleen:not palpable

Bowel sounds:yes

Central Nervous system:

 Pt is conscious

Speech: normal

Signs of meningitis:no

Cranial nerves: normal

Motor and sensory system:normal

Provisional Diagnosis:

CRF

Investigation:

Treatment:

Tab.NICARDIA 10mg PO BD

Tab.NODOSIS 50Pmg PO BD

Tab.LASIX 40mg PO BD

Tab.OROFEX XT PO OD

Tab.SHELCAL PO OD

Inj.ERYTHROPOITEIN IV Weekly once