fever projr 202422642

 Diagnosis



UREMIC ENCEPHALOPATHY

CHRONIC RENAL FAILURE

Case History and Clinical Findings

C/O SOB SINCE 10 DAYS

C/O REDUCED URINE OUTPUT SINCE 6DAYS

HOPI:

PT WAS APPARENTLY ASYMPTOMATIC 10DAYS AGO AND THEN DEVELOPED SUDDEN ONSET SOB GRADE 4(NYHA) NOT ASSOCIATED WITH CHEST PAIN, PALPITATIONS, SWEATING

C/O REDUCED URINE OUTPUT SINCE 6 DAYS

H/O PEDAL EDEMA SINCE 6 DAYS

H/O FEVER SINCE 5DAYS NOW SUBSIDED

PAST HISTORY:

K/C/O HTN SINCE 6 MONTHS ON UNKOWN MEDICATION

NOT A K/C/O DM, CVA, CAD, THYROID DISORDERS, ASTHMA, EPILEPSY


PERSONAL HISTORY

DIET: MIXED

APPETITE: NORMAL

BOWEL AND BLADDER MOVEMENTS: REGULAR.

NO KNOWN ALLERGIES AND ADDICTIONS.


FAMILY HISTORY: NOT SIGNIFICANT.

MENSTRUAL HISTORY: ATTAINED MENOPAUSE 15YRS AGO

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE.

NO PALLOR, ICTERUS, CYANOSIS, GENERALISED LYPHADENOPATHY,

PEDAL EDEMA PRESENT

TEMP: 96.8 F

PR: 120BPM

RR: 44CPM

BP : 140/80MMHG

SPO2: 98% @ RA

GRBS- 216

SYSTEMIC EXAMINATION:

CVS: S1 S2 HEARD. NO MURMURS

RS :TRACHEA- CENTRAL. BAE+, DIFFUSE B/L WHEEZE

P/A- SOFT, NON- TENDER. BOWEL SOUNDS HEARD.

CNS: NO FOCAL NEUROLOGICAL DEFECTS.

REFLEXES-RT LT

BICEPS ++. ++

TRICEPS ++ ++

SUPINATOR + +

KNEE ++ ++

ANKLE - -

Investigation

CBP HB TC N L E M B PLT SMEAR RFT UR CR UA CA+2 P NA+ K+ CL- HIV HBSAG HCVNameValueNameValueABG 23-05-2024 05:37:PM PH7.00PCO214.7PO260.6HCO33.5St.HCO35.7BEB-25.9BEecf-25.6TCO28.4O2 Sat82.1O2 Count8.1RFT 23-05-2024 05:37:PM UREA273 mg/dlCREATININE16.5 mg/dlURIC ACID11.7 mmol/LCALCIUM9.0 mg/dlPHOSPHOROUS6.9 mg/dlSODIUM140 mmol/LPOTASSIUM6.1 mmol/L.CHLORIDE108 mmol/LLIVER FUNCTION TEST (LFT) 23-05-2024 06:18:PM Total Bilurubin0.90 mg/dlDirect Bilurubin0.18 mg/dlSGOT(AST)14 IU/LSGPT(ALT)12 IU/LALKALINE PHOSPHATASE320 IU/LTOTAL PROTEINS5.9 gm/dlALBUMIN2.5 gm/dlA/G RATIO0.76Anti HCV Antibodies - RAPID23-05-2024 06:20:PMNon Reactive HBsAg-RAPID23-05-2024 06:20:PMNegative ABG 23-05-2024 06:37:PM PH7.20PCO214.1PO271.0HCO35.4St.HCO38.1BEB-21.5BEecf- 21.5TCO212.4O2 Sat92.8O2 Count6.9RFT 24-05-2024 12:22:AM UREA163 mg/dlCREATININE9.7 mg/dlURIC ACID7.2 mmol/LCALCIUM9.7 mg/dlPHOSPHOROUS4.8 mg/dlSODIUM144 mmol/LPOTASSIUM4.8 mmol/L.CHLORIDE106 mmol/LCOMPLETE URINE EXAMINATION (CUE) 24-05-2024 02:21:AM COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN++++SUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS6-8EPITHELIAL CELLS2-4RED BLOOD CELLS10- 12CRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSbacteria presentRFT 24-05- 2024 11:21:PM UREA64 mg/dlCREATININE4.2 mg/dlURIC ACID2.8 mmol/LCALCIUM9.7 mg/dlPHOSPHOROUS2.7 mg/dlSODIUM139 mmol/LPOTASSIUM4.1 mmol/L.CHLORIDE106 mmol/LPOST LUNCH BLOOD SUGAR25-05-2024 12:43:AM305 mg/dlABG 25-05-2024 10:31:PM PH7.24PCO266.9PO274.9HCO328.0St.HCO324.2BEB-0.2BEecf1.4TCO259.1O2 Sat91.8O2 Count15.2COMPLETE URINE EXAMINATION (CUE) 25-05-2024 10:49:PM COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN++++SUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS0-1RED BLOOD CELLSloadedCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilABG 25-05-2024 10:51:PM PH7.37PCO236.4PO230.6HCO320.9St.HCO321.1BEB-3.3BEecf-3.4TCO244.2O2 Sat61.3O2 Count8.3RFT 25-05-2024 10:51:PM UREA97 mg/dlCREATININE5.9 mg/dlURIC ACID4.1 mmol/LCA

LCIUM9.5 mg/dlPHOSPHOROUS3.3 mg/dlSODIUM148 mmol/LPOTASSIUM3.9 mmol/L.CHLORIDE106 mmol/L

SYNOVIAL FLUID CYTOLOGY(28/5/24): NO EVIDENCE OF ATYPICAL/ MALIGNANCY.

CULTURE SENSTIVITY( BLOOD ) (27/5/24): ESCHERICHIA COLI ISOLATED. RESISTANCE TO AMOXYCLAV,CEFTRIAXONE.

CULTURE SENSTIVITY( URINE ) (27/5/24): ESCHERICHIA COLI >10X5 CFU/ML OF URINE ISOLATED. RESISTANCE TO AMOXYCLAV,CEFTRIAXONE,COTRIMOXAZOLE,NORFLOXACIN,OFLOXCIN.

Treatment Given(Enter only Generic Name)


1) INJ.MONOCEF 1GM IV/BD

2) INJ.LASIX 40MG IV/TID

3) INJ.LEVIPIL 500MG IV/BD

4) INJ.OPTINEURIN 1AMP IN 500ML NS IV/OD

5) INJ.IPO 4000IU SC/WEEKLY ONCE

6) INJ.HAI SC/TID

7) TAB.NODOSIS 500MG PO/BD

8)TAB.PCM 650MG PO/TID

9) CAP.BIO D3 PO/ TWICE WEEKLY

10) GRBS 70 PROFILE






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