Case History and Clinical Findings
80 YEAR OLD MALE PATIENT CAME WITH C/O FEVER SINCE 1 DAY
HOPI:
PATIENT WAS APPARENTLY ALRIGHT 1 DAY BACK AFTER WHICH SHE STARTED HAVING
FEVER ,HIGH GRADE,ASSOCIATED WITH GENERALISED WEAKNESS
PATIENT WAS UNABLE TO GET UP FROM BED SINCE MORNING
H/O INVOLUNTARY PASSAGE OF STOOLS AND URINE TODAY MORNING
NO H/O NECK STIFFNES,NECK PAIN
NO H/O COUGH,COLD,BURNING MICTURATION NO H/O ALTERED SENSORIUM IN THE PAST
NO H/O HEADACHE ,VOMITINGS
H/O SIMILAR COMPLAINTS 3 YEARS BACK AND GOT HOSPITALISED
K/C/O ?CKD SINCE 15 YEARS(ON CONSERVATIVE MEDICINE)
H/O ?CVA 4 YEARS BACK
K/C/O DM 2 SINCE 20 YEARS (ON OHA'S TAB-GLIMIPERIDE 1MG + METFORMIN 500MG)
COURSE IN HOSPITALA 80 YEAR MALE CAME TO OPD WITH C/O FEVER SINCE 1 DAY,NECESSARY
INVESTIGATIONS WERE DONE AND DIAGNOSED AS
LOWER RESPIRATORY TRACT INFECTION
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
CHRONIC KIDNEY DISEASE (STAGE IIIB)
UMBILICAL HERNIA
K/C/O DM 2 SINCE 20 YEARS
.CONSERVATIVELY MANAGED, SYMPTOMS SUBSIDED. PATIENT IS HEMODYNAMICALLY
STABLE AND PLANNED FOR DISCHARGE.
O/E:
PT IS C/C/C
MILD DEHYDRATION PRESENT
BP:110/70MMHG
PR:88 BPM
RR:16 CPM
TEMP:98.4 F
GRBS-167MG/DL
CVS: S1 S2 +, NO MURMURS
CNS: NFND
RS:BAE+
NVBS HEARD
P/A: SOFT, NON TENDER, VERTICAL SCAR PRESENT
UMBILICUS -PROTURBERENT,SWELLING PRESENT AT UMBILICUS
NO SHIFTING DULLNESS AND FLUID THRILL ,BOWEL SOUNDS + Investigation
RFT 28-10-2023 04:42:PM
UREA
46 mg/dl
CREATININE
1.8 mg/dl
URIC ACID
6.4 mg/dl
CALCIUM
10.1 mg/dl
PHOSPHOROUS
2.0 mg/dl
SODIUM
135 mEq/L
POTASSIUM
4.6 mEq/L
CHLORIDE
98 mEq/L
LIVER FUNCTION TEST (LFT) 28-10-2023 04:55:PM
Total Bilurubin
1.16 mg/dl
Direct Bilurubin
0.39 mg/dl
SGOT(AST)
25 IU/L
SGPT(ALT)
14 IU/L
ALKALINE PHOSPHATE
115 IU/L
TOTAL PROTEINS
6.6 gm/dl
ALBUMIN
3.78 gm/dl
A/G RATIO 1.34
COMPLETE URINE EXAMINATION (CUE) 28-10-2023 04:55:PM
COLOUR
Pale yellow
APPEARANCE
Clear
REACTION
Acidic
SP.GRAVITY
1.010
ALBUMIN
++
SUGAR
+
BILE SALTS
Nil
BILE PIGMENTS
Nil
PUS CELLS
3-4
EPITHELIAL CELLS
2-3
RED BLOOD CELLS
Nil
CRYSTALS
Nil
CASTS
Nil
AMORPHOUS DEPOSITS
Absent
OTHERS
NilHBsAg-RAPID28-10-2023 04:55:PM
Negative
Anti HCV Antibodies - RAPID28-10-2023 04:55:PM Non Reactive
ABG 28-10-2023 06:00:PM
PH
7.42
PCO2
27.9
PO2
66.4
HCO3
18.0
St.HCO3
20.7
BEB
-4.4
BEecf
-5.5
TCO2
34.8
O2 Sat
93.4
O2 Count
20.0
SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 29-10-2023 03:49:AM
SODIUM
132 mEq/L
POTASSIUM
4.6 mEq/L
CHLORIDE
96 mEq/L
CALCIUM IONIZED
1.21 mmol/L
RFT 29-10-2023 11:38:PM
UREA
49 mg/dl CREATININE
2.0 mg/dl
URIC ACID
6.2 mg/dl
CALCIUM
10.1 mg/dll
PHOSPHOROUS
3.1 mg/dl
SODIUM
136 mEq/L
POTASSIUM
4.2 mEq/L
CHLORIDE
99 mEq/L
28/10/23
HB- 12.9
TLC-24000
PLT- 2.9
29/10/23
HB-12.9
TLC-21000
PLT-2.9
30/10/23
HB-12.7
TLC-19200
PLT-2.84
31/10/23
HB-11.9
TLC-1800
PLT-2.84 RFT:
UREA-49
CREATININE 1.2
URIC ACID-6.6
Ca-10.0
P-4.3
Na-135
K-4.3
Cl-98
USG ABDOMEN:
RAISED ECHOGENICITY OF B/L KIDNEY
LEFT LARGE RENAL CORTICAL CYST
UMBILICAL HERNIA WITH OMENTUS AS HERNIATING CONTENT
BLOOD AND URINE CULTURES-NO GROWTH FOUND
Diagnosis LOWER RESPIRATORY TRACT INFECTION CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC KIDNEY DISEASE (STAGE IIIB) UMBILICAL HERNIA K/C/O DM 2 SINCE 20 YEARS
Treatment Given(Enter only Generic Name)
1. IV FLUIDS NS,RL @ 5050ML/HOUR
2.INJ CEFTRIAXONE 2GM IV/BD
3. INJ OPTINEURON 1AMP IN 100ML NS/IV/OD
4.INJ PAN 40MG IV/OD
5. INJ HUMAN ACTRAPID INSULIN PERMEAL S/C TID AFTER INFORMING( FACULTY)
6.INJ PARACETAMOL 1GM IV/TID
7.TAB AZITHROMYCIN 500MG PO/OD
8.TAB SHELCAL-CT PO/OD
9. TAB URIMAX 0.45 PO/HS
10. VITALS MONITORING 4 HOURLY
11. GRBS 7 POINT PROFILE
12.I/O CHARTING
Advice at Discharge
1.TAB TAXIM 200MG PO/BD X5DAYS
2.TAB AZITHROMYCIN 500 PO/OD X 3DAYS
3.TAB GLIMEPIRIDE 1MG PO/OD
8AM--------X--------X
4.TAB GLIMEPIRIDE 0.5MG PO/OD X-----------X-----------8PM
5.TAB MVT PO/OD X 7DAYS
6.TAB PAN 40MG PO/OD/BBF X 5DAYS
7.TAB PCM 650MG PO/SOS
8.TAB URIMAX 0.45 PO/HS
9.TAB SHELCAL CT PO/OD
Follow Up
REVIEW TO GM OPD AFTER 1WEEK
REVIEW TO GS OPD AFTER 1WEEK
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