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4.

 Case History and Clinical Findings

 A  47 YEAR OLD FEMALE PATIENT WAS BROUGHT TO HOSPITAL WITH C/O FEVER SINCE 15 DAYS, GENERALIZED WEAKNESS SINCE 10 DAYS, BURNING MICTURITION SINCE 10 DAYS, COUGH SINCE 10 DAYS, MULTIPLE JOINT PAINS SINCE 1 WEEK OCCASIONAL IRRITABILITY PRESENT , FLUCTUATING SENSORIUM SINCE 10 DAYS

HOPI - 

PT WAS APPARENTLY ASYMPTOMATIC 15 DAYS BACK THEN HE DEVELOPED FEVER WHICH IS HIGH GRADE, ASSOCIATED WITH CHILLS AND RIGORS, CONTINUOUS, RELIEVED WITH MEDICATION, NO DIURNAL VARIATION GENERALISED WEAKNESS SINCE 10 DAYS BURNING MICTURITION SINCE 10 DAYS COUGH SINCE 10 DAYS, PRODUCTIVE COUGH, SCANTY, NON-FOUL SMELLING, NOT BLOOD STAINED MULTIPLE JOINT PAINS SINCE 1 WEEK, OCCASIONAL IRRITABILITY + FLUCTUATING SENSORIUM SINCE 10 DAYS , NOT ABLE TO IDENTIFY ATTENDERS SOMETIMES, IRRELEVANT TALK PRESENT H/O VOMITINGS SINCE 1 WEEK, NON-BILIOUS, NON PROJECTILE, NON BLOOD TINGED H/O HYPOGLYCEMIC EPISODES PRESENT, 3 EPISODES 3 MONTHS AGO

PAST HISTORY - K/C/O TYPE 2 DM SINCE 7 YRS ON UNKNOWN MEDICATION, STOPPED MEDICATION SINCE 3 MONTHS N/K/C/O HTN, TB, ASTHMA, CAD, CVA, EPILEPSY

PERSONAL HISTORY - 

DIET - MIXED

 APPETITE - NORMAL 

SLEEP - ADEQUATE 

BOWEL - REGULAR

 ADDICTIONS - CONSUMED ALCOHOL REGULARLY DAILY 2-3 QUARTERS STOPPED 4 MOTNHS AGO TOBACCO SNUFF SINCE 30 YRS ABOUT 10-12 CIGARETTES PER DAY BETEL LEAF CONSUMPTION SINCE 20 YRS

 GENERAL PHYSICAL EXAMINATION - PATIENT IS CONCIOUS, COHERENT, COOPERATIVE VITALS - 

PR - 98 BPM 

BP -160/100 MM HG 

RR - 18 CPM 

TEMP - AFEBRILE

 GRBS - 105 MG/DL 

SPO2 - 98 @ RA 

SYSTEMIC EXAMINATION - 

CVS : S1 S2 + 

RS : BAE +, TRACHEA CENTRAL , NVBS HEARD 

P/A :SOFT , NON TENDER

 CNS - NFND

 OPTHALMOLOGY REFERRAL DONE ON 20/10/23 I/V/O DIABETIC RETINOPATHY AND RAISED ICP FEATURES. IMPRESSION - HYPERTENSIVE RETINOPATHY CHANGES NOTED GRADE 3 IN BOTH EYES, NO SIGNS OF DM RETINOPATHY NOTED AND RAISED ICT AS OF NOW ADVICE - STRICT BP CONTROL REVIEW OPHTAL OPD FOR V/A &AR/REF UROLOGY REFERRAL DONE I/V/O AV FISTULA ON 24/10/23 ADVICE - USG LT UPPER LIMB ARTERIAL + VENOUS  AVOID LT UL IV CANNULATION STRESS BALL PHYSIOTHERAPY x 1 WEEK 

Investigation

 HBsAg-RAPID19-10-2023 04:39:PM Negative 

Anti HCV Antibodies - RAPID19-10-2023 04:39:PM Non Reactive 

COMPLETE URINE EXAMINATION (CUE) 19-10-2023 04:39:PM 

COLOUR Pale yellow 

APPEARANCE -CLEAR 

REACTION Acidic 

SP.GRAVITY 1.010

 ALBUMIN ++

 SUGAR Nil 

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 

BLOOD UREA19-10-2023 04:39:PM 229 mg/dl 

SERUM CREATININE19-10-2023 04:39:PM 12.7 mg/dl 

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 19-10-2023 04:39:PM

SODIUM 134 mEq/L 

POTASSIUM 5.8 mEq/L 

CHLORIDE 105 mEq/L 

CALCIUM IONIZED 1.19 mmol/L 

LIVER FUNCTION TEST (LFT) 19-10-2023 04:39:PM

 Total Bilurubin 0.70 mg/dl

 Direct Bilurubin 0.18 mg/dl SGOT(AST) 17 IU/L SGPT(ALT) 14 IU/L ALKALINE PHOSPHATE 297 IU/L TOTAL PROTEINS 6.5 gm/dl ALBUMIN 3.7 gm/dl A/G RATIO 1.30 BLOOD UREA19-10-2023 10:45:PM 226 mg/dl

SERUM CREATININE19-10-2023 10:45:PM 12.7 mg/dl SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 19-10-2023 10:45:PM SODIUM 137 mEq/L POTASSIUM 5.0 mEq/L CHLORIDE 106 mEq/L CALCIUM IONIZED 1.20 mmol/L PHOSPHOROUS19-10-2023 10:45:PM 4.7 mg/dl RFT 20-10-2023 01:14:AM UREA 150 mg/dl CREATININE 8.0 mg/dl URIC ACID 6.5 mg/dl CALCIUM 9.4 mg/dl PHOSPHOROUS 4.7 mg/dl SODIUM 135 mEq/L POTASSIUM 4.7 mEq/L CHLORIDE 102 mEq/L PERIPHERAL SMEAR20-10-2023 01:14:AM RBC : Normocytic normochromic WBC : Increased counts on smear PLATELET : Adequate IMP : Normocytic normochromic anemia with leukocytosis ABG 20-10-2023 02:03:AM PH 7.16 

PCO2 16.6 PO2 113 HCO3 5.7 St.HCO3 8.6 BEB -21.6 BEecf -21.6 TCO2 12.8 O2 Sat 97.1 O2 Count 11.5 ABG 20-10-2023 09:41:AM PH 7.33 PCO2 24.0 PO2 32.2 HCO3 12.4 St.HCO3 13.9 BEB -12.8 BEecf -12.4 TCO2 28.9

O2 Sat 78.6 O2 Count 1.8 POST LUNCH BLOOD SUGAR20-10-2023 11:03:PM216 mg/dlRFT 20-10-2023 11:03:PM UREA 121 mg/dl CREATININE 6.3 mg/dl URIC ACID 5.1 mg/dl CALCIUM 9.3 mg/dl PHOSPHOROUS 3.6 mg/dl SODIUM 136 mEq/L POTASSIUM 4.2 mEq/L CHLORIDE 99 mEq/L ABG 21-10-2023 10:52:PM PH 7.38 PCO2 28.4 PO2 74.3 HCO3 16.5 St.HCO3 16.5 BEB -7.4 BEecf -7.6 TCO2 35.8 O2 Sat 95.4 O2 Count 9.7 RFT 21-10-2023 10:52:PM UREA 132 mg/dl CREATININE 7.4 mg/dl URIC ACID 5.4 mg/dl CALCIUM 7.9 mg/dl PHOSPHOROUS 3.6 mg/dl SODIUM 136 mEq/L POTASSIUM 3.9 mEq/L CHLORIDE 102 mEq/L ABG 22-10-2023 11:21:PM PH 7.42 PCO2 37.7 PO2 71.4 HCO3 24.2 St.HCO3 24.7 BEB 0.4

0.3 TCO2 52.0 O2 Sat 96.4 O2 Count 9.9 RFT 22-10-2023 11:21:PM UREA 91 mg/dl CREATININE 4.7 mg/dl URIC ACID 3.3 mg/dl CALCIUM 9.0 mg/dl PHOSPHOROUS 3.0 mg/dl SODIUM 138 mEq/L POTASSIUM 3.9 mEq/L CHLORIDE 102 mEq/L 

2D ECHO DONE ON 19/10/23 - 

EF - 65 % MILD AR+, MILD TR+ WITH PAH, TRIVIAL MR+ NO RWMA, NO AS/MS, SCLEROTIC AV GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION + , NO PE

 USG DONE ON 19/10/23 - 

FINDINGS - E/O 12X7 MM EXOPHYTIC CYST IN RT KIDNEY MIDPOLE &8X8 MM EXOPHYTIC CYST IN LEFT KIDNEY E/O FEW TINY CALCULI NOTED IN THE LEFT KIDNEY LARGEST MEASURING 3MM MIDPOLE 

IMPRESSION - RAISED ECHOGENECITY OF RIGHT KIDNEY CORRELATE WITH RFT, B/L SIMPLE RENAL CORTICAL CYSTS, LEFT RENAL CALCULI, GRADE 1 FATTY LIVER

Diagnosis : ALTERED SENSORIUM SECONDARY TO UREMIC ENCEPHALOPATHY WITH RENAL AKI ON CKD( RESOLVING) STAGE V(RESOLVED) SECONDARY TO DIABETIC NEPHROPATHY WITH PYREXIA UNDER EVALUATION SECONDARY TO ?URTI , DM SINCE 7 YRS, DE NOVO HTN 

 Treatment Given(Enter only Generic Name) 

INJ PIPTAZ 2.25 G IV/TID INJ PAN 40 MG IV / OD INJ LASIX 40MG IV/BD TAB NICARDIA 20MG PO/BD TAB SHELCAL CT 500 MG PO/OD TAB OROFER XT PO/OD TAB LIMCEE PO/OD TAB NODOSIS 1G PO/BD INJ EPO 4000 IU SC ONCE WEEKLY INJ SUCROSE 200MG IN 100 ML NS IV/ OD INJ HAI SC/TID ACCORDING TO GRBSINJ PIPTAZ 2.25 G IV/TID Advice at Discharge TAB PAN 40 MG PO / OD TAB LASIX 40MG PO/BD TAB NICARDIA 20MG PO/BD TAB SHELCAL CT 500 MG PO/OD TAB OROFER XT PO/OD TAB LIMCEE PO/OD TAB NODOSIS 1G PO/BD INJ EPO 4000 IU SC ONCE WEEKLY INJ HAI SC/TID 8AM-1PM-8PM 4U-4U-4U 

Follow Up REVIEW TO NEPHROLOGY OPD AFTER 1 WEEK WITH HEMOGRAM , RFT REPORTS

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