PATIENT PRESENTED TO CASUALTY WITH C/O FEVER SINCE 1 WEEK, VOMITINGS SINCE 1 WEEK

 PATIENT PRESENTED TO CASUALTY WITH C/O FEVER SINCE 1 WEEK, VOMITINGS SINCE 1 WEEK( 4 EPISODES/DAY) NAUSEA PRESENT NON COMPLIANCE TO MEDICINE FOR 3 DAYS LAST WEEK AND FOR 3 DAYS THIS WEEK 


HOPI: PATIENT WEAS APPARENTLY ASYMPTOMATIC 1 WEEK AGO THEN SHE DEVELOPED FEVER OF LOW GRADE WITH CHILLS AND RIGORS ,INTERMITTENT WITH VOMITINGS( 4 EPISODES PER DAY ) ,NON PROGRESSIVE ,NON BILIOUS ,CONTAIN FOOD PARTICLES AS CONTENT K/C/O DM2 SINCE 20 YEARS( USING METFORMIN 500 MG PO/OD) K/C/O HTN SINCE 20 YEARS( USING TELMIKIND 40 MG PO/OD ,NOT USING SINCE 3 DAYS) 


ON EXAMINATION: PT IS C/C/C

NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS,LYMPHEDENOPATHY,PEDAL EDEMA VITALS: TEMP: 98.2 

PR-100 BPM 

BP: 140/80 MM HG

 RR: 16 CPM 

CVS: S1, S2+,NO MURMURS

 RS: BAE +,


PROVISIONAL Diagnosis 

DIABETIC ACIDOSIS SECONDARY TO NON COMPLIANCE (RESOLVED) WITH AKI ON CKD SECONDARY TO LEFT HYDROURETRONEPHROSIS WITH HYPERKALEMIA(RESOLVED) WITH DILATED CARDIOMYOPATHY WITH HFMEF(EF 4%) WITH HYPONATREMIA (RESOLVED) WITH K/C/O DM2 SINCE 20 YEARS WITH K/C/O HTN SINCE 20 YEARS WITH K/C/O CVA SINCE 2 MONTHS(LEFT HEMIPARESIS) 

S/P : DJ STENTING DONE ON 12/9/23



Investigation 

COMPLETE URINE EXAMINATION (CUE) 05-09-2023 07:29: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 Nil

 LIVER FUNCTION TEST (LFT) 05-09-2023 07:29:PM 

Total Bilurubin 0.64 mg/dl1-0 mg/dl

 Direct Bilurubin 0.20 mg/dl0.2-0.0 mg/dl

 SGOT(AST) 18 IU/L31-0 IU/L

 SGPT(ALT) 14 IU/L34-0 IU/L 

ALKALINE PHOSPHATE 197 IU/L98-42 IU/L

 TOTAL PROTEINS 6.5 gm/dl8.3-6.4 gm/dl 

ALBUMIN 3.7 gm/dl5.2-3.5 gm/dl 

A/G RATIO 1.32 

RFT 05-09-2023 07:29:PM 

UREA 75 mg/dl42-12 mg/dl 

CREATININE 4.0 mg/dl1.1-0.6 mg/dl

 URIC ACID 6.6 mg/dl6-2.6 mg/dl

 CALCIUM 9.4 mg/dl10.2-8.6 mg/dl 

PHOSPHOROUS 2.1 mg/dl4.5-2.5 mg/dl 

 SODIUM 129 mEq/L145-136 mEq/L

 POTASSIUM 4.6 mEq/L5.1-3.5 mEq/L

 CHLORIDE 103 mEq/L98-107 mEq/L 

RFT 06-09-2023 04:29:AM 

UREA 62 mg/dl42-12 mg/dl 

CREATININE 3.6 mg/dl1.1-0.6 mg/dl

 URIC ACID 6.0 mg/dl6-2.6 mg/dl

 CALCIUM 9.7 mg/dl10.2-8.6 mg/dl 

PHOSPHOROUS 2.4 mg/dl4.5-2.5 mg/dl 

SODIUM 128 mEq/L145-136 mEq/L

 POTASSIUM 4.0 mEq/L5.1-3.5 mEq/L 

CHLORIDE 101 mEq/L98-107 mEq/L 


ABG 06-09-2023 07:51:AM 

PH 7.33 PCO2 20.3 PO2 90.9

 HCO3 10.5 St.HCO3 13.6 

 BEB -13.8 

BEecf -14.3 

TCO2 22.7 

O2 Sat 96.9

 O2 Count 11.5

 BLOOD UREA07-09-2023 05:25:AM 108 mg/dl42-12 mg/dl 

SERUM CREATININE07-09-2023 05:25:AM 5.4 mg/dl1.1-0.6 mg/dl 

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 07-09-2023 05:25:AM SODIUM 147 mEq/L145-136 mEq/L 

POTASSIUM 5.8 mEq/L5.1-3.5 mEq/L

 CHLORIDE 97 mEq/L98-107 mEq/L 

CALCIUM IONIZED 1.20 mmol/Lmmol/L 

BLOOD UREA08-09-2023 10:51:AM 94 mg/dl42-12 mg/dl 

SERUM CREATININE08-09-2023 10:51:AM 5.1 mg/dl1.1-0.6 mg/dl 

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 08-09-2023 10:51:AM SODIUM 148 mEq/L145-136 mEq/L 

POTASSIUM 5.7 mEq/L5.1-3.5 mEq/L 

CHLORIDE 96 mEq/L98-107 mEq/L

  CALCIUM IONIZED 1.14 mmol/Lmmol/L

 ABG 09-09-2023 05:32:AM

 PH 7.29 

PCO2 25.5 

PO2 46.3 

HCO3 12.0

 St.HCO3 14.1

 BEB -13.0 

BEecf -13.3

 TCO2 25.8 

O2 Sat 78.6 

O2 Count 10.5

 BLOOD UREA09-09-2023 09:05:AM 97 mg/dl42-12 mg/dl 

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 09-09-2023 09:05:AM SODIUM 128 mEq/L145-136 mEq/L

 POTASSIUM 5.4 mEq/L5.1-3.5 mEq/L 

CHLORIDE 96 mEq/L98-107 mEq/L

 CALCIUM IONIZED 1.12 mmol/Lmmol/L 

 SERUM CREATININE09-09-2023 09:05:AM 5.3 mg/dl1.1-0.6 mg/dl 

BLOOD UREA10-09-2023 04:47:AM 168 mg/dl42-12 mg/dl 

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 10-09-2023 04:47:AM SODIUM 128 mEq/L145-136 mEq/L

 POTASSIUM 5.6 mEq/L5.1-3.5 mEq/L 

CHLORIDE 96 mEq/L98-107 mEq/L 

CALCIUM IONIZED 1.07 mmol/Lmmol/L 

SERUM CREATININE10-09-2023 04:47:AM 6.9 mg/dl1.1-0.6 mg/dl 

POST LUNCH BLOOD SUGAR11-09-2023 09:44:AM 159 mg/dl140-0 mg/dl

 BLOOD UREA11-09-2023 11:36:PM 82 mg/dl42-12 mg/dl 

SERUM CREATININE11-09-2023 11:36:PM 6.4 mg/dl1.1-0.6 mg/dl 

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 11-09-2023 11:36:PM SODIUM 128 mEq/L145-136 mEq/L

 POTASSIUM 5.3 mEq/L5.1-3.5 mEq/L 

CHLORIDE 98 mEq/L98-107 mEq/L

 CALCIUM IONIZED 1.15 mmol/Lmmol/L 

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 12-09-2023 08:16:PM SODIUM 129 mEq/L145-136 mEq/L

 POTASSIUM 4.9 mEq/L5.1-3.5 mEq/L

 CHLORIDE 97 mEq/L98-107 mEq/L 

CALCIUM IONIZED 1.27 mmol/Lmmol/L 

BLOOD UREA12-09-2023 11:08:PM 87 mg/dl42-12 mg/dl

 SERUM CREATININE12-09-2023 11:08:PM 6.2 mg/dl1.1-0.6 mg/dl 

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 12-09-2023 11:08:PM SODIUM 128 mEq/L145-136 mEq/L 

POTASSIUM 5.3 mEq/L5.1-3.5 mEq/L 

CHLORIDE 97 mEq/L98-107 mEq/L 

CALCIUM IONIZED 1.04 mmol/Lmmol/L

 BLOOD UREA13-09-2023 10:43:PM 203 mg/dl42-12 mg/dl 

SERUM CREATININE13-09-2023 10:43:PM 8.3 mg/dl1.1-0.6 mg/dl

 SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 13-09-2023 10:43:PM SODIUM 134 mEq/L145-136 mEq/L 

POTASSIUM 5.5 mEq/L5.1-3.5 mEq/L

 CHLORIDE 98 mEq/L98-107 mEq/L

 CALCIUM IONIZED 1.01 mmol/Lmmol/L

 HEMOGRAM: 5/9 6/9 7/9 8/9 9/9 10/9 11/9 12/9 13/9 14/9

 HB: 7.1 7.4 7.4 7.5 7.9 8 7.6 7.1 6.1 7.2 

 TLC: 27800 24000 23300 25000 25000 24300 21700 19200 16700 20600

 PLC: 3.03 3.03 3.0 3.59 3.22 3.3 3.10 3 2.95 2.96 


USG: LEFT KIDNEY: 9.3 X 4.1 CM PCS AND PROX URETER MILDLY DILATED AT THE SITE OF NAROWING NO OBVIOUS CALCULUS SEEN RIGHT KIDNEY: 9.2 X 3.8 CM MILD ASCITES


Treatment Given(Enter only Generic Name) 

1. INJ HAI 1ML IN 39 ML NS @ 1ML/HR +

 INJ 10% DEXTROSE @ 50 ML/HR FOR 3 DAYS

 2. IV FLUIDS 0.45% NS @ 50 ML/HR 

3. INJ PAN 40 MG IV/OD 

4. INJ PIPTAZ 2.25 MG IV/TID FOR 9 DAYS

 5. INJ ZOFER 4 MG IV/SOS 6. TAB. PCM 650 MG PO/SOS

 7. INJ NEOMOL 1 GM IV/SOS 

8. TAB. ECOSPRIN AV 75/10 PO/HS 

9. TAB. TELMIKIND 40 MG PO/OD FOR 6 DAYS

 10. INJ. LASIX 40 MG IV/ INFUSION FOR 6 DAYS 11. SYP LACTULOSE 5 ML/PO/BD 

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