65y/F
65 year old female, house wife by occupation, came to the opd with c/o burning micturition since 2weeks.
Generalised weakness since 2 weeks
Low backache since 1 week.
Fever since 5-6 days
History of present illness:
Patient was apparently asymptomatic 2 weeks back. Then she developed c/o burning micturition since 2 weeks and used tab.nitrofurantoin for 4 days and UTI subsided. Followed by c/o low backache, followed by fever since 5 days. Low grade fever not associated with chills and rigor, relieved on medication, followed by generalised weakness.
H/o covid-19 3 months back
No c/o cold, cough
No c/o chest pain, palpitations, syncopal attacks
No c/o orthopnea, PND
K/c/o Dm- 2 since 25 years.
Medication used : lispro insulin(50%) + insulin lispro protamine(50%) (25U - X - 25U)
Hypertension since 25 years
Medication used : pro Met-xl 50 mg
She is having similar c/o UTI twice a year since 5-6 years
H/o (?) Angina 4 years back. On isosorbide dinitrate/SOS
No h/o epilepsy, tb, asthma
No c/o pedal edema, facial puffiness, decreased urine output.
Personal history:
Appetite : Normal
Bowel and bladder movements : Normal
Non alcoholic
Non smoker
Family history:
No significant family history
Patient is drowsy, coherent and cooperative
General examination :
Patient was drowsy
Pallor +
No icterus -
No Cyanosis
No clubbing, lymphadenopathy and oedema
Temp : afebrile
PR : 110 BPM
RR : 24 CPM
BP : 110/80 mm of Hg
Spo2 : 98% at RA.
GRBS : 148 mg/dl
Systemic examination :
CVS:
S1,S2 heard
NO thrills, murmurs.
Respiratory system:
Trachea postion : central
Inspiratory crepts noted
B/L IAA, ISA
Per abdomen:
Soft, non tender
No palpable masses
CNS:
All superficial and deep reflexes are normal
Diagnosis : AKI on CKD secondary to urosepis.
K/c/o diabetes and hypertension since 25 years
K/C/O : Hypothyroidism
With Hypoproliferative Anemia
VITALS AND TEMPERATURE MONITORING:
INVESTIGATIONS:
1. ECG :
2 CHEST X-RAY [ AP SUPINE]
•2D ECHO :
• URINE FOR CULTURE SENSITIVITY :
3. ABG :
ON 2/8/2021:
ON 3/8/2021:
ON 4/08/2021:
4. Hemogram:
5. CUE:
5. THYROID PROFILE :
6. LFT :
7. RFT :
8. Serum urea, creatinine, electrolytes :
On 2/08/2021:
On 3/08/2021:
On 4/08/2021:
On 5/08/21 :
Urea : 121
Creatinine : 4.2
On 6/08/21 :
Urea : 132
Creatinine : 4.2
On 7/08/21:
Urea : 121
Creatinine : 4.1
9. PLBS :
10. FBS :
11. RETICULOCYTE COUNT :
12. CUE :
13. RTPCR :
TREATMENT :
DAY 1 :
Inj.Meropenem 500m Iv/BD
Inj.levofloxacin500mgIv/OD
Inj.pan40mg iv/OD
Inj.Hai sc t.i.d
Inj.lasix40mg Iv/BD
Strict I/O charting
GRBS Charting 6th hourly
Bp/PR/RR/SPO2 Charting 4th hourly
Neb.Duolin 8th hourly
Budecort 8th hourly
Mucomist 12th hourly
IVF 500ml NS@u.ot 40ml/hr
Day 2 :
Inj.Meropenem 500mgIv/bd
Inj.levofloxacin500mgIv/od
Inj.pan40mg iV/od
Inj.Hai sc t.i.d
Inj.lasix40mg Iv/bd
Strict I/O charting
Bp/PR/RR/spo2 charting
Neb.Duolin 6th hourly
-budecort 8th hourly
IVF 500ml NS @u.o+40ml/hr
Syp.lactulose15ml/po/bd
Day 3 :
Same as day 2.
Day 4 :
Same as day 3.
Syp.Cremaffin plus 15ml PO/BD
Tab. Flucanozole 100mg/PO/BD
Day 5:
Same as day 4.
Day 6:
Same as day 4.
Tab. Tamsulosin 0.4 mg/PO/HS
Tab. Thyronom 50 microgram/PO/OD
Tab. Ultracet 1/2 tablet /PO/QID
Inj. Piptaz 4.5g/IV/STAT
Day 7 :
Same as day 6.
Inj. Piptaz 2.25g/IV/TID
DEPARTMENT OF GENERAL-MEDICINE
DISCHARGE SUMMARY
Age/Gender : 65Years/Female
Discharge Type: Relieved
Admission Date: 2/07/2021
Discharge Date
Date:9/07/2021
Ward:MEDICINE WARD
Unit:1
Name of Treating Faculty
DR. Vijay dhanush (INTERN)
DR. Akshitha(INTERN)
DR. Valli(INTERN)
DR. Pallavi(INTERN)
DR. Vinay PGY1
DR. Shashikala PGY2
DR. Usha PGY2
DR. Aashitha PGY2
DR. Hareen (SR)
DR. ARJUN KUMAR (AP)
DR. RAKESH BISWAS (HOD)
Diagnosis :
AKI on CKD secondary to urosepis.
K/c/o diabetes and hypertension since 25 years
K/C/O : Hypothyroidism
With Hypoproliferative Anemia
Case history and clinical findings :
Patient was apparently asymptomatic 2 weeks back. Then she developed c/o burning micturition since 2 weeks and used tab.nitrofurantoin for 4 days and UTI subsided. Followed by c/o low backache, followed by fever since 5 days. Low grade fever not associated with chills and rigor, relieved on medication, followed by generalised weakness.
H/o covid-19 3 months back
No c/o cold, cough
No c/o chest pain, palpitations, syncopal attacks
No c/o orthopnea, PND
K/c/o Dm- 2 since 25 years.
Medication used : lispro insulin(50%) + insulin lispro protamine(50%) (25U - X - 25U)
Hypertension since 25 years
Medication used : pro Met-xl 50 mg
She is having similar c/o UTI twice a year since 6 years
H/o (?) Angina 4 years back. On isosorbide dinitrate/SOS
No h/o epilepsy, tb, asthma
No c/o pedal edema, facial puffiness, decreased urine output.
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