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10

 Case History and Clinical Findings

A 50 YEAR OLD MALE WITH C/O COUGH SINCE 20 DYAS,FEVER SINCE 1 WEEK

SHORTNESS OF BREATH SINCE 5 DAYS

BILATERAL PEDL EDEMA SINCE 30 DAYS

DECERASED URINE OUTPUT SINCE 1 DAY

ALTERED SENSORIUM SINCE 8 HRS

PATIENT WAS APPARENTLY ASYMPTOMATIC 20 DAYS AGO THEN HE DEVELOPED COUGH

SINCE 20 DAYS,PRODUCTIVE TYPE WITH YELLOWISH WHITE COLOURED SPUTUM,SCANTY

IN NATURE,NOT BLOOD TINGED AND FOUL SMELLING

FEVER SINCE 1 WEEK,LOW GRADE,NOTT ASSOCIATED WITH CHILLS AND RIGORS

SHORTNESS OF BREATH SINCE 5 DAYS INSIDIOUS IN ONSET AND GRADUALLY

PROGRESSIVE PROGRESSED FROM GRADE 2 TO GRADE 4.ORTHOPNEA PRESENT NO PND.

BILATERAL PEDAL EDEMA SINCE 3 DAYS,DECREASED URINE OUTPUT ,N/H/O

VOMITINGS,LOOSE STOOLS,PAIN ABDOMEN K/C/O HTN SINCE 3 YEARS NOT ON REGULAR MEDICATION

CKD SINCE 6 MONTHS ON CONSERVATIVE MANAGEMENT

PERSONAL HISTORY :

DIET :MIXED

APPETITE : GOOD

SLEEP : ADEQUATE

BOWEL:REGULAR

ALCHOL ISTORY- OCASSIONAL SINCE 20 YEARS STOPPED 6 MONTHS BACK

GENERAL EXAMINATION : PATIENT IS CONSCIOUS , COHERENT , COOPERATIVE

PALOR -NO

PEDAL EDEMA - BILATERALLY PRESENT

NO SIGNS OF CLUBBING , ICTERUS , CYANOSIS , LYMPHEDNOPATHY

VITALS :

TEMP : 986.8 F

PR : 88 BPM

BP : 210/100 MMHG

GRBS : 133 MG / DL

SPO2 : 98%

RR : 21 CPM

SYSTEMIC EXAMINATION :

CVS : S1 , S2 HEARD , NO MURMURS

RS : FINES CREPS PRESENT IN BILATERAL LOWER BACK

PA :SOFT,NT, NO ORGANOMEGALY

CNS : NFAD

COURSE IN THE HOSPITAL:

PATIENT WAS ADMITTED I/V/O COUGH SINCE 20 DAYS, FEVER SINCE 1 WEEK

SHORTNSS OF BREATH SINCE 5 DAYS, B/L PEDAL EDEMA SINCE 30 DAYS, DECREASE

URINE OUTPUT SINCE 1 DAY AND ALTERED SENSORIUM SINCE 8HRS AND WAS

INVESTIGATED FURTHER AND ON EVALUATION WAS DIAGNOSED AS AKI SECONDARY TO

LRTI ON CKD ( STAGE V) WITH HYPONATREMIA ( ? DILUSIONAL) WITH ANEMIA- MCHC, K/C/O

HTN WITH RETINOPATHY.

NEPHROLOGY REFERAL WAS DONE I/V/O SOB SINCE 5 DAYS WHICH IS GRADE II TO III

MMRC AND B/L PEDAL EDEMA SINCE 3 DAYS.

RX FLUID RESTRICTION <1.5L/DAY

SALT RESTRICTION <2 LIT/ DAY

IVF 2 NS @ 50ML/HR

INJ 3% NS @ 10ML/HR

INJ PIPTAZ 2.25GM/IV/TID

INJ LASIX 20ML/IV/BD

TAB NICARDIA RETARD 20ML /PO/BD

OPHTHAMOLOGY REFERRAL WAS DONE I/V/O RAISED ICP FEATURES, HYPERTENSIVE

RETINOPATHY CHANGES

FUNDUS EXAMINATION DONE ON 3/11/23

IMPRESSION- NO RAISED ICT FEATURES

HYPERTNSIVE RETINOPATHY GRADE III CHANGES NOTED.

Investigation

COMPLETE URINE EXAMINATION (CUE) 03-11-2023 05:05:PM

COLOUR

Pale yellow

APPEARANCE

Clear

REACTION

Acidic

SP.GRAVITY

1.010

ALBUMIN

++

SUGAR

+

BILE SALTS

Nil

BILE PIGMENTS

Nil

PUS CELLS

4-5

EPITHELIAL CELLS 2-3

RED BLOOD CELLS

Nil

CRYSTALS

Nil

CASTS

Nil

AMORPHOUS DEPOSITS

Absent

OTHERS

Nil

HBsAg-RAPID03-11-2023 05:05:PM

Negative

Anti HCV Antibodies - RAPID03-11-2023 05:05:PM

Non Reactive

BLOOD UREA03-11-2023 05:05:PM

108 mg/dl

42-12 mg/dl

SERUM CREATININE03-11-2023 05:05:PM

6.2 mg/dl

1.3-0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 03-11-2023 05:05:PM

SODIUM

99 mEq/L

145-136 mEq/L

POTASSIUM

3.7 mEq/L

5.1-3.5 mEq/L

CHLORIDE

92 mEq/L

98-107 mEq/L

CALCIUM IONIZED

0.94 mmol/L

mmol/L PHOSPHOROUS03-11-2023 05:05:PM

3.5 mg/dl

4.5-2.5 mg/dl

LIVER FUNCTION TEST (LFT) 03-11-2023 05:05:PM

TOTAL BILIRUBIN

0.86 mg/dl

1-0 mg/dl

Direct Bilurubin

0.20 mg/dl

0.2-0.0 mg/dl

SGOT(AST)

85 IU/L

35-0 IU/L

SGPT(ALT)

30 IU/L

45-0 IU/L

ALKALINE PHOSPHATE

370 IU/L

128-53 IU/L

TOTAL PROTEINS

5.4 gm/dl

8.3-6.4 gm/dl

ALBUMIN

3.5 gm/dl

5.2-3.5 gm/dl

A/G RATIO

1.93

ABG 03-11-2023 05:18:PM

PH

7.34

PCO2

12.5

PO2

144 HCO3

6.6

St.HCO3

10.4

BEB

-18.4

BEecf

-18.7

TCO2

14.4

O2 Sat

97.7

O2 Count

9.6

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 03-11-2023 11:54:PM

SODIUM

100 mEq/L

145-136 mEq/L

POTASSIUM

3.7 mEq/L

5.1-3.5 mEq/L

CHLORIDE

87 mEq/L

98-107 mEq/L

CALCIUM IONIZED

0.88 mmol/L

mmol/L

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 04-11-2023 01:13:AM

SODIUM

100 mEq/L

145-136 mEq/L

POTASSIUM

3.6 mEq/L

5.1-3.5 mEq/L CHLORIDE

84 mEq/L

98-107 mEq/L

CALCIUM IONIZED

0.92 mmol/L

mmol/L

BLOOD UREA04-11-2023 03:31:AM

128 mg/dl

42-12 mg/dL

SERUM CREATININE04-11-2023 03:31:AM

7.3 mg/dl

1.3-0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 04-11-2023 03:31:AM

SODIUM

104 mEq/L

145-136 mEq/L

POTASSIUM

3.5 mEq/L

5.1-3.5 mEq/L

CHLORIDE

90 mEq/L

98-107 mEq/L

CALCIUM IONIZED

0.90 mmol/L

mmol/L

ABG 04-11-2023 09:42:AM

PH

7.35

PCO2

13.2

PO2

139

HCO3 7.1

St.HCO3

10.9

BFB

-17.6

BEecf

-17.9

TCO2

15.6

O2 Sat

97.9

O2 Count

9.6

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 04-11-2023 01:15:PM

SODIUM

112 mEq/L

145-136 mEq/L

POTASSIUM

4.0 mEq/L

5.1-3.5 mEq/L

CHLORIDE

92 mEq/L

98-107 mEq/L

CALCIUM IONIZED

0.90 mmol/L

mmol/L

USG WAS DONE ON 3/11/23:

IMPRESSION:

B/L GRADE III RPD CHANGES AND MIMINAL ASCITIS.

MDCT BRAIN PLAIN - NO ABNORMALITY IN BRAIN

-GENERALISED INCREASE IN BONE DENSITY, CONSISTENT WITH SKELETAL CHANGES OF

CKD

Diagnosis AKI SECONDARY LOWER RESPIRATORY TRACT INFECTION ON CKD ( STAGE V ) WITH TRUE HYPONATREMIA -? DILUTIONAL WITH ANEMIA-MIHC K/C/O HTN WITH HYPERTENSION WITH RETINOPATHY

Treatment Given(Enter only Generic Name)

INJ CEFTRIAXONE 1GM IV/BD

TAB.NICARDIA 10 MG PO/TID

INJ.LASIX 40 MG IV/BD

SYP.ASCORIL LS 10 ML PO/TID

TAB NODOSIS 500 MG PO/TID

TAB.SHELCAL 500MG PO/OD

INJ IRON SUCROSE 200MG IN 100ML NS IV / ALTERNATE DAYS X 5 TIMES IN A WEEK

SYP POTKLOR 10ML IN 1 GLASS OF WATER PO/TID

Advice at Discharge

INJ CEFTRIAXONE 1GM IV/BD

TAB.NICARDIA 10 MG PO/TID

INJ.LASIX 40 MG IV/BD

SYP.ASCORIL LS 10 ML PO/TID

TAB NODOSIS 500 MG PO/TID

TAB.SHELCAL 500MG PO/OD

INJ IRON SUCROSE 200MG IN 100ML NS IV / ALTERNATE DAYS X 5 TIMES IN A WEEK

SYP POTKLOR 10ML IN 1 GLASS OF WATER PO/TID

Follow Up

REVIEW TO GM OPD AFTER 1 WEEK

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