80 YR OLD MALE WITH SOB, LOSS OF APPETITE, COUGH

202420808 chandra reddy
CASE HISTORY AND CLINICAL FINDINGS
CHIEF COMPLAINTS:
PATIENT CAME WITH CHIEF COMPLAINTS OF SOB SINCE 1 DAY
LOSS OF APPETITE SINCE 7 DAYS
COUGH SINCE 7 DAYS
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 7 DAYS AGO AND HE DEVELOPED COUGH
SINCE 7 DAYS ,CONTINUOUS TYPE,NOT ASSOCIATED WITH SPUTUM,DRY COUGH,SORE
THROAT, NO AGGRAVATING AND RELIEVING FACTORS ASSOCIATED WITH LOSS OF
APPETITE SINCE 7 DAYS,WEIGHT LOSS AND SOB SINCE 1 DAY(GRADE2 MMR).
N/H/O FEVER,COLD,ALLERGIES,BURNING MICTURITION,CONSTIPATION,PAIN ABDOMEN
PAST HISTORY:
N/K/C/O HTN,DM,CVA,CAD,EPILEPSY,THYROID DISORDER,ASTHMA,TB
GENERAL EXAMINATION:
PATIENT CONCIOUS COHERENT COOPERATIVE
TEMP 96.5F
PULSE 111 BPM
RR 27/MIN
BP 100/70 mmHg
SPO2 98%
GRBS:96 MG/DL
NO ICTERUS PALLOR CYANOSIS LYMPHADENOPATHY CLUBBING
SYSTEMIC EXAMINATION:
CVS:S1S2 HEARD , NO MURMURS.
RS :BAE NORMAL, NVBS
CNS :NO FOCAL NEUROLOGIC DEFICIT
P/A:SOFT,NON TENDER,NO ORGANOMEGALY
DIALYSIS DONE ON 15/5/24
INVESTIGATION
CBP HB TC N L E M B PLT SMEAR RFT UR CR UA CA+2 P NA+ K+ CL- HIV HBSAG HCV
ABG 11-05-2024 11:15:PMPH 7.16PCO2 17.3PO2 97.8HCO3 5.9St.HCO3 8.8BEB -21.4BEecf -
21.3TCO2 13.2O2 Sat 96.2O2 Count 12.4
COMPLETE URINE EXAMINATION (CUE) 11-05-2024 11:15:PMCOLOUR Pale
yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR NilBILE
SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS
NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilRFT 12-05-2024
12:05:AMUREA 201 mg/dlCREATININE 5.0 mg/dlURIC ACID 8.7 mmol/LCALCIUM 10.0
mg/dlPHOSPHOROUS 6.0 mg/dlSODIUM 139 mmol/LPOTASSIUM 4.7 mmol/L.CHLORIDE 106
mmol/L
COMPLETE URINE EXAMINATION (CUE) 12-05-2024 05:56:AMCOLOUR Pale
yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR NilBILE
SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS
NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilBLOOD UREA 12-05-
2024 03:14:PM 188 mg/dl
SERUM CREATININE 12-05-2024 03:14:PM 5.0 mg/dlABG 12-05-2024 03:14:PMPH 7.181PCO2
17.6PO2 41.5HCO3 6.3St.HCO3 9.2BEB -20.7BEecf -20.7TCO2 13.9O2 Sat 76.1O2 Count 10.6
RFT 12-05-2024 11:48:PMUREA 189 mg/dlCREATININE 5.1 mg/dlURIC ACID 9.1 mmol/LCALCIUM
10.2 mg/dlPHOSPHOROUS 5.4 mg/dlSODIUM 141 mmol/LPOTASSIUM 4.5 mmol/L.CHLORIDE 106
mmol/L
13/5/2024
HEMOGRAM:
HB:7.1
TLC:9200
RBC:2.39
PLT:2.0
RFT:
UREA:189
CREATININE:5.1
NA:141
K:4.5
CL:106
DIAGNOSIS
CHRONIC RENAL FAILURE
TREATMENT GIVEN
1.IV FLUIDS NS@75ML/HR
2.INJ.CEFTRIAXONE 1GM IV/BD
3.INJ PAN 40 MG IV/OD/8AM
4.TAB .TAMD 0.4 PO/HS
5.TAB NODOSIS 1000MG PO/OD TID
6.INJ LASIX 40MG IV/IF SBP 110 MMHG
7.STRICT I/O CHARTING
ADVICE AT DISCHARGE
1.INJ PAN 40 MG IV/OD/8AM
2.TAB .TAMD 0.4 PO/HS
3.TAB NODOSIS 1000MG PO/OD TID
4.INJ LASIX 40MG PO/BD

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