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13.

 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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