73 YR OLD FEMALE WITH BREATHLESSNESS ON EXERTION

202413659 naramma
CASE HISTORY AND CLINICAL FINDINGS
C/O BREATHLESSNESS ON EXERTION SINCE 4 DAYS
HOPI
PATIENT WAS APPARENTLY ASYMPTOMATIC 4 DAYS BACK THEN DEVELOPED
BRETHLESSNESS ON EXERTION INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE GRADE II
NYHA RELIEVED WITH REST. ASSOCIATED WITH ORTHOPNEA AND PND, NO SYNCOPE
,PALPITATIONS PRESENT.
NO H/O COUGH COLD FEVER EXCESSIVE SWEATING
H/O PEDAL EDEMA PITTING IN TYPE EXTENDING UPTO KNEE
NO H/O PAIN ABDOMEN BURNING MICTURITION
H/O DECREASED URINE OUTPUT
PAST HISTORY-
K/C/O HTN SINCE 3 YEARS ON TAB TELMA 40MG
N/K/C/O DM-II/CVA/CAD/THYROID/SEIZURE DISORDERS
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS ,COHERENT , COPERATIVE
TEMPERATURE- 98.6 F
PR 84 BPM
RR 16CPM
BP 110/70 MMHG
SYSTEMATIC EXAMINATION
CVS S1S2 + NO MURMURS
RS BAE+
CNS NFND
P/A : SOFT AND NON TENDER. NO ORGANOMEGALY.
SURGERY REFFERAL WAS DONE I/V/O BURNING SENSATION DURING DEFECATION
DIAGNOSIS- ACUTE FISSURE IN ANO
ADVISED-
SYRUP CREMAFFIN 5ML/PO/HS
OINT SMUTH FOR LA
SITZ BATH WITH POVIDINE IODINE WITH LUKEWARM WATER
TAB PAN 40MG PO/OD, HIGH FIBRE DIET
REVIEW SOS
OPHTALMOLOGY REFFERAL WAS DONE I/V/O RETINOPATHY CHANGES
IMPRESSION - FUNDUS EXAMINATION OF BOTH EYES - GRADE III HYPERTENSIVE
RETINOPATHY CHANGES NOTED IN LEFT EYE
AND RIGHT EYE FUNDUS EXAMINATION COULDNOT BE ELICITED DUE TO PRESENCE OF
PCO
GASTRO REFFERAL WAS DONE I/V/O BLACK COLOURED STOOLS AND PAIN ABDOMEN
ADVISED-
INJ PAN 4GM IV TID
URO REFFERAL WAS DONE I/V/O LEFT HYDROURETERONEPHROSIS ON26/03/24
ADVISED-
NCCT KUB AND REVIEW WITH SERUM CREATININE AND BLOOD UREA
REVIEW URO REFFERAL WAS DONE ON 29/03/24-
ADVISED- SYRUP ALKASTONE B6 15ML IN 100ML OF WATER TWICE DAILY
INVESTIGATION
COMPLETE BLOOD PICTURE (CBP) 27-03-2024 11:13:AMHAEMOGLOBIN 7.5 gm/dl 17.0-13.0
gm/dlTOTAL COUNT 8900 cells/cumm 10000-4000 cells/cummNEUTROPHILS 80 % 80-40
%LYMPHOCYTES 11 % 40-20 %EOSINOPHILS 00 % 6-1 %MONOCYTES 9 % 10-2 %BASOPHILS
00 % 2-0 %PLATELET COUNT 1.20SMEAR Normocytic normochromic blood picture with
thrombocytopenia
COMPLETE BLOOD PICTURE (CBP) 30-03-2024 11:13:AMHAEMOGLOBIN 14.6 gm/dl 17.0-13.0
gm/dlTOTAL COUNT 5400 cells/cumm 10000-4000 cells/cummNEUTROPHILS 70 % 80-40
%LYMPHOCYTES 20 % 40-20 %EOSINOPHILS 00 % 6-1 %MONOCYTES 10 % 10-2
%BASOPHILS 00 % 2-0 %PLATELET COUNT 1.0SMEAR Normocytic normochromic blood picture
with thrombocytopenia
COMPLETE BLOOD PICTURE (CBP) 29-03-2024 11:13:AMHAEMOGLOBIN 9.7 gm/dl 17.0-13.0
gm/dlTOTAL COUNT 12500 cells/cumm 10000-4000 cells/cummNEUTROPHILS 80 % 80-40
%LYMPHOCYTES 10 % 40-20 %EOSINOPHILS 00 % 6-1 %MONOCYTES 08 % 10-2
%BASOPHILS 00 % 2-0 %PLATELET COUNT 1.20SMEAR Normocytic normochromic blood picture
with thrombocytopenia and leukocytosis
RFT -30-03-2024
BLOOD UREA- 57MG/DL
URIC ACID 6.2 MMOL/L
SERUM CREATININE 2,2MG/DLSERUM ELECTROLYTES (Na, K, C l)SODIUM 133 mmol/L 145-
136 mmol/LPOTASSIUM 3.4 mmol/L 5.1-3.5 mmol/LCHLORIDE 103 mmol/L 98-107 mmol/L
RFT -29-03-2024
BLOOD UREA- 60MG/DL
URIC ACID 7.3 MMOL/L
SERUM CREATININE 1.9MG/DLSERUM ELECTROLYTES (Na, K, C l)SODIUM 132 mmol/L 145-
136 mmol/LPOTASSIUM 3.4 mmol/L 5.1-3.5 mmol/LCHLORIDE 97 mmol/L 98-107 mmol/L
LIVER FUNCTION TEST (LFT) 29-03-2024 Total Bilurubin 0.97 mg/dlDirect Bilurubin 0.20 mg/dl 0.2-
0.0 mg/dlSGOT(AST) 14 IU/L 35-0 IU/LSGPT(ALT) 12 IU/L 45-0 IU/LALKALINE PHOSPHATASE
142 IU/L 119-56 IU/LTOTAL PROTEINS 5.1 gm/dl 8.3-6.4 gm/dlALBUMIN 2.5 gm/dl 4.6-3.2
gm/dlA/G RATIO 0.98
STOOL FOR OCCULT BLOOD - NEGATIVE
COMPLETE URINE EXAMINATION (CUE) 30-03-2024COLOUR Pale yellowAPPEARANCE
ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN traceSUGAR NilBILE SALTS NilBILE
PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS
NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil
CT SCAN - ABDOMEN(PLAIN) DONE ON 27/03/24:
IMPRESSIONLEFT URETERIC CALCULUS
LEFT MODERATE HYDROURETERONEPHROSIS
CHOLELITHIASIS
USG DONE ON 25/3/24-
IMPRESSION-
CHOLELITHIASIS
LEFT KIDNEY SHOWS RAISED ECHOGENECITY WITH FOCAL CALIECTASIS AND
HYDROURETERO NEPHROSIS
2D ECHO DONE ON 25/03/24-
NO RWMA
MILD TR WTH PAH TRIVIAL AR NO MR
SCLEROTIC AV NO AS/MS IAS-INTACT
EF-65% RVSP 28+10=38MMHG
GOOD LV SYSTOLIC FUNCTION
GRADE I DIASTOLIC DYSFUNCTION
MILD DE +
IVC SIZE 0.5CMS COLLAPSING

DIAGNOSIS
LEFT HYDRO URETERONEPHROSIS
POST RENAL AKI SECONDARY TO URETERIC OBSTRUCTION
K/C/O HYPERTENSION SINCE 3 YEARS
1PINT PRBC TRANSFUSION DONE ON 27/03/24
TREATMENT GIVEN
1PINT PRBC TRANSFUSION DONE ON 27/03/24
IV FLUIDS 1 PINT NS @ U.O +30ML/HR
INJ AUGMENTIN 625MG IV/BD
INJ NEOMOL 1GM IV/SOS (TEMP>101F)
INJ ONDEM 4MG IV/BD
INJ LASIX 40MG IV/BD
NEB WITH BUDECORT-12TH HRLY PLUS IPRAVENT - 6TH HRLY
TAB CLOPITAB AV 75/20 PO/HS
INJ OPTINEURON 1AMP IN 100ML NS IV OD
INJ IRON SUCROSE 200MG IN 100ML NS IV ON ALTERNATE DAYS
ORS SACHET IN 1 LITRE OF WATER
TAB LARIAGO DS 1KIT/PO
PROTEIN POWDER 1 TEASPOON IN 1 GLASS OF MILK/BD
INJDOXYCYCLINE 100MG IV/BD
INJ CLINDAMYCIN 600MG IV/OD
INJ CEFTRIAXONE 1 MG IV/BD
SYPRUP ALKASTONE B6 15ML IN GLASS WATER TWICE DAILY
TAB TAMSULOSIN 0.4MG PO/HS
TAB.DOXYCYCLINE 100MG PO/BD
TAB CLINDAMYCIN 600MG PO/BD
TAB GUDCEF CV 200MG PO/BD
TAB P650MG PO/BD
TAB ZOFER PO/BD
TAB MVT PO/OD
TAB LARIAGO DS
3 EGG WHITES PER DAY
TAB LASIX 20MG PO/BD
MONITOR VITALS
ADVICE AT DISCHARGE
TAB CLOPITAB AV 75/20 PO/HS X 10DAYS
TAB TAMSULOSIN 0.4MG PO/HS X 10DAYS
TAB.DOXYCYCLINE 100MG PO/BD X 10DAYS
TAB CLINDAMYCIN 600MG PO/BD X 10DAYS
TAB LASIX 20MG PO/BD X 10DAYS
TAB PAN 40MG PO/OD X 10DAYS
TAB MVT PO/OD X 10DAYS
Follow Up
REVIEW TO GM OPD AFTER 10 

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