A 58 year old male with fever,vomitings,decreased apetite,decreased urine output since 15 days

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CASE: 

A 58 year old male came with chief complaints of 

-fever since 15 days

-decreased apetite since 15 days

-decreased urine output since 15 days

-vomitings since 10 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 16 days back. He went to another hospital where he complained of decreased micturation, shortness of breath (grade 4).He was then referred to here.

He then developed high grade fever which was continuous and not relieved by medication.

He complained of vomitings since 10 days which occurs immediately after having food,non bilious and one episode of blood stained of vomiting.

He also complained of burning micturation and decreased urine output since 15 days.

DAILY ROUTINE:

He wakes up in the morning around 6-7 am. He has his tea and breakfast. He stays at home all day and watches tv. In the evening he does beedi and drinks alcohol with friends.He skips dinner when he drinks alcohol.At night he sleeps around 7-8 pm.

PAST HISTORY:

Not a known case of HTN,asthma,epilepsy

Patient is a known case of diabetes mellitus since 10 years

He had a history of Tuberculosis 20 years ago for which he had taken medication for 9 months.

10 years ago, he developed lower limb weakness for which he was taken to the hospital.The physician had told him that he has low levels of sodium and potassium.He was diagnosed with diabetes at the same time. He was given medication.

Since then he stopped going to work (occupation: farmer).

PERSONAL HISTORY: 

Sleep: decreased

Diet:mixed

Apetite: reduced

Addictions: alcohol since 30 years and smokes beedi since 30 years 

(1 pack a day).

GENERAL EXAMINATION: 

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy: absent

Pedal edema: absent

VITALS:

Temperature: 98.4 degree farenheit

Pulse: 79 bpm

Respiratory rate: 16 cpm

Blood pressure: 100/70 mm hg

SpO2: 96%

SYSTEMIC EXAMINATION:

CVS:S1 and S2 are heard

Respiratory: bilateral vesicular breath sounds are presents

CNS: no focal neurological deficits

Abdomen: soft and non tender 

shape of abdomen: scaphoid

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

AKI on CRF secondary to diabetic nephropathy 

Old Kochs

H/o hypokalemic periodic paralysis

TREATMENT:

Inj. Piptaz 2.25gm TID

Inj. NS infusion 10ml/hour

Inj. Pan 40mg iv OD

Inj.Lasix 20 mg BD

Inj. Neomol