62 year old female with UTI

 GENERAL MEDICINE 

A 62 year old female, homemaker by occupation, came to the casualty with chief c/o fever since morning a/w b/l loin pain since 4 days, burning micturition and SOB (Grade 4). She also c/o neck pain and low back ache since 4 days.

HISTORY OF PRESENT ILLNESS : Patient was apparently asymptomatic 2 years ago and then developed bilateral loin pain not a/w pedal edema or facial puffiness. It was diagnosed to be CKD for which she has been taking medication. The patient  developed burning micturition, b/L loin pain, low back ache and neck pain (restriction of movement +) since 4 days. She had fever since morning which was relieved on medication and was not a/w chills and rigor. Patient also c/o SOB (Grade 4). No complaints of Orthopnea, PND, pedal edema, chest pain, palpitations. 

PAST HISTORY  :

No h/o HTN, DM, Epilepsy, CAD, TB. 

Patient is a k/c/o CKD since 2 years and is on conservative treatment. 

FAMILY HISTORY : NAD

PERSONAL HISTORY :

Diet - Mixed

Appetite - Normal 

Bowel - Regular

Bladder - Decreased 

Sleep - Adequate

Addictions - None 

GENERAL EXAMINATION :

No Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Pedal edema. 

VITALS :

PR - 90 bpm

BP - 130/80 mm Hg 

RR - 23 cpm

SpO2 - 98% 

GRBS - 110mg/dl 

SYSTEMIC EXAMINATION : 

CVS - S1, S2 heard, No thrills, No murmurs 

Respiratory - Trachea position : central, NVBS heard, BAE + 

 P/A - Soft, non tender, bowel sounds heard, Liver and spleen not palpable

CNS - Conscious, Speech:normal, no signs of meningeal irritation, motor and sensory system normal, reflexes present

2-07-2021

INVESTIGATIONS- 

ABG 

CUE 

HEMOGRAM 

RBS 

BLOOD UREA 

SERUM CREATININE 

LFT 

URINARY ELECTROLYTES 

URINE PROTEIN / CREATININE RATIO 

ECG 

USG 

RT-PCR 

         

4-07-2021

HEMOGRAM 

CBP

RFT

BLOOD UREA 

SERUM CREATININE 

 

5-07-2021

BLOOD UREA 

SERUM CREATININE 

HEMOGRAM 

6-07-2021

URINE CULTURE 

HEMOGRAM

FEVER CHART 

Final diagnosis : Urinary Tract Infection with Chronic Kidney Disease Stage 5 (Analgesic Nephropathy) with denovo HTN 

TREATMENT GIVEN : 

DAY 1 (2-07-2021)

Inj. PIPTAZ 4.5gm IV 

Inj. PAN 40mg IV OD

DAY 2 (3-07-2021) 

IVF NS 0.9% 2 units NS @75ml/hr 

Inj. PIPTAZ 2.25gm IV BD

Inj. PAN 40mg IV OD 

Tab. ULTRACET PO QID 

DAY 3 (4-07-2021) 

IVF NS 0.9% 2 units NS @75ml/hr 

Inj. PAN 40mg IV/OD 

Inj. PIPTAZ 2.25gm IV/TID   

Tab. ULTRACET 1 tab x BD 

 Tab. LASIX 20mg PO/BD 

Tab. MYOSPAZ PO/OD 

DAY 4 (5-07-2021) 

Inj. PIPTAZ 2.25gm IV/TID continue today and tomorrow  

Tab. ULTRACET 1 tab x BD x 5 days 

 Tab. LASIX 20mg PO/BD x 5days 

Tab. MYOSPAZ PO/OD x 5 days 

 Tab. Nicardia 20mg PO/BD

DAY 5 (6-07-2021) 

DISCHARGED 

75 year old male with CKD

A 75 YEAR OLD MALE PATIENT WITH CHRONIC KIDNEY DISEASE ( CKD) 

Date of admission: 01.07.2021

CHIEF COMPLAINTS:

On 1.7.21

A 75 year old male came to OPD with the chief complaints of:

• Itching all over the body since 15 days

•Shortness of breath (grade III) since 10 days (dyspnoea on exertion) 

• Pedal edema (pitting type) - which was present since 1 year but aggravated in the past 10 days

HISTORY OF PRESENT ILLNESS:

• The patient was apparently asymptomatic 1 year ago and then developed pedal edema  (pitting type, intermittent and gradual in onset) and has been on conservative treatment since then. Aggravated with alcohol or smoking. 

•He was also diagnosed with hypertension a year back and was on medication. 

• Since the past 1 year, he complained of shortness of breath, which aggravated in the past 10 days. It affected patient's daily routine, relieves on rest, medication and sitting position. Aggravated during night time in sleep, he wakes up gasping for air, positional variation, where in supine posture aggravation is seen, also aggravated when patient smokes. Associated with cough and mucoid sputum. 

• He complains of itching all over his body since the last 15 days. 

• He has no h/o fever and no h/o decreased urine output and burning micturition, no h/o altered sleep cycles, no h/o of chest pain and palpitations. 

HISTORY OF PAST ILLNESS:

The patient was a known case of :

• Scrotal swelling since past 20 years. 

• UCD since the past one year and also had been on conservative treatment. 

• Hypertension since 1 year

• He sometimes complained of burning micturition . 

• Not a k/c/O of DM, asthma, tuberculosis, stroke, CAD. 

DRUG HISTORY:

• He has been on conservative drug treatment for pedal edema ( UCD) and hypertension for the past one year, but the name was not specified. 

• No treatment history of Diabetes, CAD, asthma, tuberculosis, Antibiotics, hormones, Chemo radiation and blood transfusion. 

PERSONAL HISTORY : 

• No h/o of any altered sleep patterns. 

• He follows a mixed diet and appetite is normal. 

• Difficulty in passing stools since 1 month (only on alternate days). 

• Normal micturition. 

• He has been consuming alcohol occasionally (in a much diluted form) for the past 35-40 years,last drink was 2 months back. 

• He has been smoking (chutta) for the past 35-40 years, the last smoke was 10 days back. 

FAMILY HISTORY : 

• No family history of hypertension, diabetes, heart diseases, kidney diseases, asthma, Tuberculosis and stroke. 

GENERAL EXAMINATION:

• Pt. is conscious, coherent, cooperative

• Moderately built and moderately nourished. 

• Pallor present

• No icterus and cyanosis

• No lymphadenopathy

• Mild dehydration is present

VITALS: ( on 01.07.2021) 

1. Temperature - 103°F

2. Pulse rate - 90 bpm

3. BP - 140/70 mmHg 

4. Respiratory rate - 18cpm 

5. SPO2  at room air - 84 %

               - 100 on 11lt

6. RBS - 101mg/dl

VITALS: (on 04.07.2021) 

1. Temperature : 98.4°F

2. Pulse rate : 98

3. BP : 160/100 mmHg

4 Respiratory rate : 24

5. SPO2 at ra - 94%

SYSTEMIC EXAMINATION :

A. CARDIOVASCULAR SYSTEM

• S1 and S2 heard

• On auscultation, rt. Side cardiac rub +

• No thrills 

• No cardiac murmurs

B. RESPIRATORY SYSTEM

• Wheezing sounds heard on auscultation of right lung. 

• BAE +

• Normal Vesicular breath sounds present

• Trachea is central in position

• Dyspnea present

C. EXAMINATION OF THE ABDOMEN

• soft, non - tender

• No complaint of abdominal tightness

• No organomegaly

• Scaphoid shape of abdomen

• No tenderness, no palpable mass, no free fluid, no bruits

• Hernial orifices - normal

• Normal bowel sounds

D. CENTRAL NERVOUS SYSTEM

•Pt. is conscious, coherent and cooperative. 

• Speech is normal. 

•No neck stiffness and kerning's sign

Cranial nerves, motor system and sensory system are normal. 

• No focal neurological deficit. 

PROVISIONAL DIAGNOSIS :

 ? CHRONIC KIDNEY DISEASE WITH NEED FOR DIALYSIS. 

 ? CHOLELITHIASIS

 ? UREMIC PRURITIS ( RENAL PRURITIS) 

INVESTIGATIONS:

On 1.7.21:

A. BIOCHEMICAL INVESTIGATIONS:

1. Serum Creatinine

2 . Blood Urea

3.Random Blood Sugar

B. PATHOLOGICAL INVESTIGATIONS

1.Hemogram

C. ULTRASOUND REPORT:

D. MICROBIOLOGICAL EXAMINATION:

• HBsAg - Rapid test - negative

• HIV 1/2 Rapid test - negative

• Anti HCV antibodies - negative

• SARS CoV2 PCR test - negative

On 4.7.21:

A. ABG REPORT

B. HEMOGRAM :

C. LFT : 

D. RFT :

E. BLOOD GROUPING and RH TYPE :

F. SERUM IRON :

On : 6.7.21 :

A  . ABG :

B. HEMOGRAM :

C. RFT :

D. ECG : 

TREATMENT :

On 1.7.21

• head end elevation to treat SOB and tachypnoea

• NTG 1gm 4ml - for cardiac rub

On 4.7.21

• salt ( <2g/day) and fluid (<1l/day) restriction

• Inj. Lasix

• Tab. Nodosis

• Tab  Shelca

• Tab Oeofex

On cross consultation : ( 4.7.21) 

DVL : UREMIC PRURITIS

• Moisturex soft lotion

• Liquid paraffin

• Atarax anti itch lotion

Adviced for serum transferring saturation

51 year old female with SOB

patient came with shortness of breath, altered sensorium, GRBS high and urine ketones positive.

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 Chief complaints;-

A 51 year old female patient is a known case of diabetes mellitus since 20 yrs. She was initially on OHA and 

since 3 years on insulin 20 units in the morning and 10 units in evening.

 Now she came with chief complaints of 

Pain in right hypochondrium and epigastrium since 4 days.

No h/o blood in vomitus.

Patient has loss of appetite since 2 days.

Patient didn't take her regular dose of insulin, As she didn't eat anything.

 No h/o fever, pain abdomen, loose stools, no h/o cough.

N/o yellow discoloration of eyes, pedal edema, chest pain, palpitations.

She has c/o altered sensorium, on 12/06/2021 early morning.

Past history - 

H/o hysterectomy 20 yrs back.

No H/o hypertension,asthma, epilepsy, TB.

 Personal history - 

Diet - mixed, 

Appetite decreased since 2 days

Bowel and bladder - regular .

no  addictions.

 Vitals - 

Bp -150/100 mm Hg

PR -134 bpm

RR - 32 cpm 

TEMP - Afebrile

SPO2 :-100% on room air

GRBS:- HIGH (>500) AT ADMISSION.

On examination-

Patient is conscious, coherent, cooperative.

Abdominal examination-

Tenderness in Right hypochondrium and epigastrium.

No palpable mass.

 

Cvs- 

S1 S2 heard,

No thrills, no murmurs.

Respiratory system -

BAE - present 

           Nvbs.

 CNS - intact.

  Investigations - 

ECG - 

Treatment -

1. IV fluids 

2. Insulin infusion

Discharge summary -

1601006046 Short case

 GENERAL MEDICINE 

 A 46 year old female, resident of Nalgonda, who is a housewife came to the outpatient department with the chief complaint of shortness of breath since 5 days. 

History of presenting illness: 

The patient was apparently asymptomatic 5 days ago and then she developed shortness of breath which was insidious in onset, gradually progressive, aggravated on lying down and relieved on medication.

Associated with orthopnea, wheeze, paroxysmal nocturnal dyspnea. 

Anasarca and cough with expectoration since 5 days which was insidious in onset. 

Known case of COPD since 12 years and is on inhaler. 

Personal history- 

Chronic smoker since 20 years.

General Examination: 

Raised JVP

Respiratory System examination: 

• Inspection- normal

• Palpation- normal

• Auscultation- bilateral decreased breath sounds and bilateral rhonchi and crepitations present at infrascapular and infraaxillary areas.

CVS Examination-  

• Inspection- normal

• Palpation-

*left parasternal heave

*palpable P2

*apex beat at 5th intercostal space, lateral to midclavicular line

• Auscultation -S1,S2 heard

Loud P2, No murmurs

Findings- 

• Right atrium and ventricle- dilated

• RVSP- 85 mm of Hg 

• Severe TR with PAH

1601006046 Long case

 GENERAL MEDICINE

A 65 year old male, resident of Veliminedu, Chityal who is a mason by occupation came to the outpatient department on 12th of April 2021 with the chief complaints of swelling in both the legs since 14 days and altered sensorium since 2 days. 

History of presenting illness: 

The patient was apparently asymptomatic 14 days ago, he then developed swelling in both the legs which was insidious in onset, gradually progressive, grade 3 pitting oedema, aggravated on rest and relieved by walking. It was associated with facial puffiness which was noticeable early in the morning. History of decreased urine output since 10 days. Members of the family complained of abnormal behaviour such as inappropriate shouting since 2 days. 

Not associated with nausea, vomiting, dyspnea, fatigue, abdominal pain, cough or palpitations. 

Past history: 

Similar complaints of pedal oedema and decreased urinary output were present 5 months ago. The patient took medication (Furosemide 10mg) prescribed by a local doctor and stopped the medication once the symptoms subsided. 

He is a known case of hypertension from 9 years and is taking Metaprolol and Amilodipine since then. 

Not a known case of diabetes mellitus, tuberculosis, asthma and seizures. 

Personal history: 

Diet: Mixed 

Appetite: Decreased

Bowel and bladder: Regular 

Sleep: Adequate 

Addictions: None 

Family history: 

No significant family history. 

Treatment history: 

He has been put on dialysis since admission and has completed 6 sessions. 

Torsemide 10 mg since 5 months. 

General examination: 

Patient was in altered sensorium while examining. 

Temperature: Afebrile 

Pulse rate: 82 bpm, regular in rhythm 

Blood pressure: 110/70 mm of Hg 

Respiratory rate: 16 cycles per min 

Pupils: Bilateral reacting to light

JVP is normal 

Physical examination: 

Pallor: present 

Icterus: absent 

Cyanosis: absent 

Clubbing: absent 

Oedema: absent 

Lymphadenopathy: absent 

Central nervous system examination: 

GCS: E4V3M4 

Motor system- 

                               Right               Left 

Tone: 

Upper limb -           Normal          Normal 

Lower limb -           Normal          Normal 

Reflexes: 

Biceps -                  2+                   2+ 

Supinator -             2+                    2+ 

Triceps -                 2+                    2+ 

Knee -                     2+                    2+ 

Ankle -                    1+                    1+ 

Babinski -             Negative           Negative 

• All superficial reflexes are intact. 

• Sensory and cranial nerves: not able to assess. 

Per abdomen examination: 

Umbilicus midline and inverted 

Soft, non tender and no organomegaly 

No shifting dullness or fluid thrill. 

Bowel sounds are present. 

Kidneys were not palpable bimanually. 

CVS examination: 

S1, S2 sounds are heard. No murmurs, apex beat heard at left 5th ICS, medial to MCL.

Respiratory system examination: 

Normal vesicular breath sounds heard. 

Bilateral air entry present. 

Investigations: 

Complete blood picture- 

 

Complete urine examination- 

Ultrasound abdomen- 

Chest X-ray- 

 

Provisional diagnosis: Chronic Kidney disease leading to uremic encephalopathy.