General medicine


Case:Acute kidney injury

45 year old female came to casuality with chief complaints of vomitings, nasuea.

Complaints and duration:
Patient was apparently normal 4 years back then she developed burning micturition,pedal edema,right loin pain for which she visited local hospital and diagnosed with right renal calculi(2-3cms)   pyelonephritis then reffered to NIMS in nims patient underwent right nephrectomy in 2018 since then patient had no complaints.

History of present illness:
Since 10-15 days patient had nausea and vomitings  epigastric discomfort,4-5 episodes of vomitings
Small quantity food particles as contents.
No blood in vomiting.
No history of fever.

History of past illness:
Right nephrectomy in 2018

HISTORY OF TREATMENT:.
-Diabetes: No
--Hypertension: No
-CAD:No
--Asthma: No
-Tuberculosis: No
--Antibiotics: No
-hormones: No

Personal history:
•marital status-married
•occupation--farmer
•appetite--lost
•Bowels--regular
•micturition--abnormal
•known allergies--no

Family history:
There is no similar complaints in family members.
 
physical examination:
Pallor is absent
-No icterus
--No cyanosis
-No clubbing of feet and toes
- edema of feet-- yes
-lymphadenopathy: No
-malnutrition--no
--Dehydration:no
Vitals:
-temperature: afebrile
-Pulse rate :82
--BP mm/ Hg : 130/80 arm mm hg
-Respiration count(count for a full min) rate--16/min
-spo2 at room air--98%

Diagnosis:
Acute kidney injury
Investigations:
Ultrasound-








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