202333425

 

Case History and Clinical Findings

C/O LOW GRADE FEVER,BURNING MICTURITION,BLOATING OF ABDOMEN SINCE 10DAYS ALSO C/O SOB,DECREASED APPETITE SINCE 10DAYS

HOPI:

PATIENT WAS APPATENTLY ASYMPTOMATIC 10DAYS BACK THEN HE DEVELOPED LOW GRADE FEVER WITH CHILLS,INTERMITTENT IN NATURE,TEMPORARILY RELIEVED ON MEDICATION ASSOCIATED WITH BURNING MICTURITION SINCE 10DAYS

C/O BURNING MICTURITION,HESIATANCY,URGENCY,DRIBBING OF URINE AND DECREASED STREAM.

C/O BLOATING SENSATION,BELCHING,SINCE 10DAYS

C/O PRODUCTIVE COUGH SINCE 10DAYS,SOB SINCE 10DAYS

NO C/O VOMITING,LOOSE STOOLS,CHEST PAIN,ORTHOPNOEA,PND,PEDAL EDEMA ALSO INFORMED THAT HE HASN'T PASSED STOOLS SINCE 4DAYS

PAST HISTORY:

DIAGNOSED WITH DM2 10DAYS BACK

N/K/C/O HTN,CVA,TB,ASTHMA,EPILEPSY AND THYROID

 

PERSONAL HISTORY:

APPETITE-DECREASED SINCE 10DAYS

BOWEL AND BLADDER-CONSTIPATION AND BURNING MICTURITION SINCE 10DAYS SLEEP-ADEQUATE

H/O TODDY CONSUMPTION SINCE 20 TO 30 YEARS NO H/O ALLERGY TO FOOD OR DRUGS

GENERAL EXAMINATION:

PATIENT IS CONSIOUS, COHARENT AND COOPERATIVE

NO PALLOR, ICTERUS,CLUBBING, CYNOSIS, LYMPADENOPATHY,EDEMA

 

 

VITALS:

BP:130/70MMHG PR:82 BPM RR:16 CPM SPO2:98%'

SYSTEMIC EXAMINATION:

CVS S1, S2+ NO MURMURS HEARD RS: BAE+

P/A: SOFT,TENDERNESS PRESENT IN EPIGASTRIC REGION BOWELS SOUNDS ARE NOT CLEARLY HEARD ON AUSCULTATION CNS:NFND

 

COURSE IN THE HOSPITAL:-

PATIENT CAME WITH THE ABOVE MENTIONED COMPLAINTS , THOROUGH CLINICAL EXAMINATIONS , AND NECCEASARY INVESTIGATIONS WERE DONE

USG ABDOMEN SUGGESTED FEATURES OF UTI , PT WAS STARTED ON IV ANTIBIOTICS , AS THE PT WAS HAVING COUGH WITH SPUTUM AND WITH CHEST X RAY SHOWING B/L PLURAL EFFUSION. ON ADMISSION PATIENT UREA AND CREATININE WERE 78 MG/DL AND 1.9 . AT THE TIME OF DISCHARGE 38MG/DL AND 1.4

PATIENT WAS DIAGNOSED DENOVO DIABTES MELLITUS AND SUGARS WERE MANAGED WITH INJ.HAI AND LATER WAS CONVERTED TO OHS AT THE TIME OF DISCHARGE SPUTUM WAS SENT FOR CULTURE AND CBNAT . SYMTOMATIC TREATMENT WAS GIVEN .

PT WAS SYMTAMATICALLY IMPROVED AND DISCHARGED UNDER HEMODYNAMICALLY

STABLE CONDITION

 

Investigation

CHEST XRAY-B/L MILD PLEURAL EFFUSION(RIGHT>LEFT) , RETICULAR OPACITIES NOTED IN LOWER ZONES OF B/L LUNG -LIKELY CONSOLIDATIVE CHANGES , B/L PROMINENET HILA 2D ECHO- EF;63IVC COLLAPSINGMODERATE TR+PAH;MILD MR+,TRIVIAL AR+NO RWMA,NO

AS/MS SCLEROTIC AVGOOD LV SYSTOLIC FUNCTIONDIASTOLIC DYSFUCTION+USG

ABDOMENLEFT COMPLEX RENAL CYSTB/L GRADE 1 RPD CHANGES NOTEDRIGHT SIMPLE RENAL CORTICAL CYSTINTERNAL ECHOS NOTED IN THE URINARY BLADDER ?

CYSTITISUSG CHESTRIGHT MILD PLEURAL EFFUSION WITH UNDERLYING LUNG COLLAPSE WITH CONSOLIDATORY CHANGES NOTEDLEFT MILD PLEURAL EFFUSION WITH

CONSOLIDATORY CHANGES NOTEDBGT-O positiveRBS-121mg/dlFBS-119mg/dlHemogram ON 30/7/23Hb-9TLC-18,500Neutrophil-85Lymphocytes -7PCV-25.2MCHC-35.7RBC-3.27Platelet-

2.66RFT on 30/7/23Urea-78Creatine - 1.9Na+ -134K+ - 3Cl- 98LFTTotal bilirubin -0.79Direct bilirubin

-0.19SGOT-80SGPT-63ALP-302Albumin-3.88A/G-2.94CUEAlbumin+Sugar-nilPus cells-3-4Epithelial cells-2-3Dengue NS1-negativeSmear for malaria parasite-negative31/7/23RFTUrea-28Creatine -

1.7Na+ -130K+ - 3.1Cl- 100HemogramHb-9.2TLC-14,300MCV-76.9MCH-28.0RBC-3.17Platelet-

2.3SPOT URINE PROTEIN-12SPOT URINE CREATINE-23.3RATIO-0.51HEMOGRAM ON

1/8/23Hb-13.5TLC-8,500MCV-75.3MCH-27.1RBC-3.17Platelet-2.09RFT ON 1/8/23Urea-61Creatine -

1.7Na+ -130K+ - 3.4Cl- 98CUE ON 1/8/23ALB-TRACESUGAR-NILPUS CELLS-1-2RED BLOOD CELLS-6-7RFT ON 4/08/2023Urea-38Creatine - 1.4Na+ -137K+ - 3.6Cl- 9824 HR URINARY PROTINE ; 218 MG/DL24 HR URINARY CREATININE;1.0 G/DAY24 HR URINARY VOLUME ; 4000 MLSR.OSMOLARITY ;281.9 m OSM/KGABG ;PH;7.54PO2 ; 64.4 mmHgPCO2;44.1

mmHgHCO3;38.0 mmo/L

Treatment Given(Enter only Generic Name)

1) I.V NS 50ML/HR

2) INJ.PAN 40MG PO/OD

3) INJ.MONOCEF 1GM IV/BD

4) INJ.LASIX 20MG IV/BD

5) INJ.HAI SC/TID ACCORDING TO BLOOD GLUCOSE LEVELS

6) SYP.CITRALKA PO/TID(10ML)

7) SYP.CREMAFIN PO/BD

8) TAB.METACLOPRAMIDE 10MG PO/BD

9) TAB.ZOFER PO/SOS

10)  SYP.ASCORYL PO/TID

11)  TAB.DOLO 650MG PO/TID

12)  GRBS 7HR PROFILE

 

Advice at Discharge

1] TAB. GLICLAZIDE 50 MG /PO/OD/8AM

2]   TAB.PAN 40MG PO/OD [BF] AT 7AM X1 WEEK

3) SYP.CREMAFIN PO/BD X 5 DAYS

4) TAB.METACLOPRAMIDE 10MG PO/BD X 1 WEEK

5) TAB.ZOFER PO/SOS

6) SYP.ASCORYL PO/TID X1 WEEK 8AM-1PM-8PM [10ML]

7) TAB.DOLO 650MG PO/SOS

8] STRICT DIABETIC DIET


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