31 YR OLD FEMALE WITH SOB AND COUGH

202420807 sampurna
CASE HISTORY AND CLINICAL FINDINGS
PATIENT PRESENTED WITH C/O SOB SINCE 5 DAYS
COUGH SINCE 3 DAYS
PATIENT WAS APPARENTLY ASYMPTOMATIC 5 DAYS AGO THEN SHE DEVELOPED
SHORTNESS OF BREATH SINCE 5 DAYS COUGH SINCE 3 DAYS PRODUCTIVE IN NATURE
H/O VOMITING
NO H/O HEADACHE FEVER
H/O TYPHOID 1 WEEK BACK

K/C/O HTN SINCE 1 YEAR
K/C/O THYROID SINCE 7 YEARS
N/K/C/O DM EPILEPSY TB CVA CAD
ON EXAMINATION
PATIENT IS CONCIOUS COHERENT COOPERATIVE
TEMP 97.3F
PULSE 96 BPM
RR 20/MIN
BP 140/100mmHg
SPO2 98%
NO PALLOR ICTERUS CLUBBING CYANOSIS GENERALISED LYMPADHENOPATHY
SYSTEMIC EAMINATION
CVS S1 S2 +
RS BAE+
CNS NAD
PA SOFT NT BS+
INVESTIGATION
NameValueNameValueAnti HCV Antibodies - RAPID11-05-2024 05:15:PMNon Reactive HBsAg-
RAPID11-05-2024 05:15:PMNegative RFT 11-05-2024 06:59:PM UREA223 mg/dlCREATININE10.6
mg/dlURIC ACID10.7 mmol/LCALCIUM10.0 mg/dlPHOSPHOROUS9.8 mg/dlSODIUM139
mmol/LPOTASSIUM4.6 mmol/L.CHLORIDE106 mmol/LABG 11-05-2024 06:59:PM
PH7.06PCO27.6PO2110HCO35.0St.HCO32.1BEB-27.4BEecf-27.2TCO24.8O2 Sat92.5O2
Count9.6LIVER FUNCTION TEST (LFT) 11-05-2024 10:29:PM Total Bilurubin0.64 mg/dlDirect
Bilurubin0.15 mg/dlSGOT(AST)14 IU/LSGPT(ALT)12 IU/LALKALINE PHOSPHATASE309
IU/LTOTAL PROTEINS6.5 gm/dlALBUMIN3.6 gm/dlA/G RATIO1.27COMPLETE URINE
EXAMINATION (CUE) 11-05-2024 10:53:PM COLOURPale
yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN++SUGARNilBILE
SALTSNilBILE PIGMENTSNilPUS CELLS4-5EPITHELIAL CELLS2-4RED BLOOD
CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilRFT 12-05-2024
05:36:AM UREA242 mg/dlCREATININE11.0 mg/dlURIC ACID11.8 mmol/LCALCIUM9.7
mg/dlPHOSPHOROUS10.6 mg/dlSODIUM140 mmol/LPOTASSIUM3.9 mmol/L.CHLORIDE106
mmol/LT3, T4, TSH 12-05-2024 05:36:AM T30.50 ng/mlT42.44 micro g/dlTSH424.49 micro Iu/mlABG
12-05-2024 07:00:AM PH7.13PCO29.0PO2129HCO32.9St.HCO35.7BEB-25.5BEecf-
25.5TCO26.6O2 Sat94.3O2 Count7.8RFT 12-05-2024 11:44:PM UREA220 mg/dlCREATININE10.7
mg/dlURIC ACID11.0 mmol/LCALCIUM9.2 mg/dlPHOSPHOROUS9.8 mg/dlSODIUM140
mmol/LPOTASSIUM4.2 mmol/L.CHLORIDE106 mmol/LRFT 13-05-2024 10:42:PM UREA206
mg/dlCREATININE9.6 mg/dlURIC ACID10.9 mmol/LCALCIUM9.1 mg/dlPHOSPHOROUS9.3
mg/dlSODIUM139 mmol/LPOTASSIUM3.8 mmol/L.CHLORIDE106 mmol/LCOMPLETE BLOOD
PICTURE (CBP) 13-05-2024 10:42:PM HAEMOGLOBIN6.9 gm/dlTOTAL COUNT9000
cells/cummNEUTROPHILS66 %LYMPHOCYTES25 %EOSINOPHILS01 %MONOCYTES08
%BASOPHILS00 %PLATELET COUNT2.1SMEARNormocytic normochromic anemiaT3, T4, TSH 15-
05-2024 07:24:AM T30.50 ng/mlT42.44 micro g/dlTSH424.49 micro Iu/mlRFT 15-05-2024 11:12:AM
UREA214 mg/dlCREATININE11.0 mg/dlURIC ACID10.2 mmol/LCALCIUM10.0
mg/dlPHOSPHOROUS9.2 mg/dlSODIUM139 mmol/LPOTASSIUM4.0 mmol/L.C
HLORIDE106 mmol/L
DIAGNOSIS
ACUTE ON CKD
K/C/O HYPOTHYROIDISM
TREATMENT GIVEN
FLUID RESTRICTION <1.5L/DAY
SALT RESTRICTION ,1G/DAY
INJ PIPTAZ 2.25GM /IV/TID
INJ PAN 40MG IV/OD/8AM
INJ EPO 4000 IU/SC /WEEKLY ONCE
INJ LASIX 40MG IV/BD
TAB THYRONORM 125MG PO/5AM/BBF
TAB PCM 650MG /SOS
TAB SPOROLAC 2 TABS /PO/TID
CAP REDOTEL PO/BD
MONITOR VITALS 4 HOURLY
ADVICE AT DISCHARGE
FLUID RESTRICTION <1.5L/DAY
SALT RESTRICTION <2G/DAY
TAB.NODOSIS 500MG PO/BD
TAB SHELCAL CT PO/OD
TAB OROFER XT PO/OD
TAB PHENYTOIN 100MG PO/OD
TAB NICARDIA 10MG BD

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