58/M PTB CKD

 CHIEF COMPLAINTS:

A 50YEAR OLD MALE PATIENT RESIDENT OF NALGONDA PRESENTED TO OPD WITH COMPLAINTS OF

SHORTNESS OF BREATH SINCE 15 DAYS

DIFFICULTY IN SWALLOWING SINCE 15 DAYS

DECREASED APETITE SINCE 15 DAYS

FEVER SINCE 1 WEEK

HISTORY OF PRESENTING ILLNESS: 

PATIENT WAS APPARANTLY ASYMPTOMATIC 6 MONTHS BACK, THEN HE DEVELOPED SHORTNESS OF BREATH, COUGH FOR 10 DAYS AND WAS TAKEN TO HOSPITAL

FEVER SINCE 15 DAYS, LOW GRADE, ASSOCIATED WITH CHILLS, INTERMITTENT, EVENING RISE OF TEMPRATURE +, COUGH PRODUCTIVE, SPUTUM-MUCOID, COPIOUS, NON BLOOD TINGED.

DECREASED EPISODE A/WPAIN DURING SWALLOING AND BURNING SENSATION

IN EPIGASTRIUM.

SOB-INSIDIOUS ONSET, GRADUALLY PROGRESSED GRADE 2-3

PAIN DURING SWALLOWING AND DIFFICULTY DURING SWALOWING ( SOLIDS ›LIQUIDS).

NO H/O PAIN ABDOMEN,VOMITINGS, NASUEA, BURNING MICTURITION, LOOSE STOOLS, DECREASED URINEOUTPUT, FACIAL PUFFINES, DISTENSION OF ABDOMEN, CHEST PAIN,PALPITATIONS.

HISTORY OF PAST ILLNESS:

N/K/C/O DM, HTN, ASTHMA. CAD, TB,THYROID DISORDERS.

FAMILY HISTORY:

NO SIGNIFICANT FAMILY HISTORY.

PERSONAL HISTORY:

DIET :MIXED

APPETITE: LOST

SLEEP: ADEQUATE

BOWEL: NORMAL

BLADDER HABITS: REGULAR

ADDICTIONS:ALCOHOL-REGULAR(STOPPED YEAR BACK)

SMOKING-BEEDI-1PACK/DAY.

GENERAL EXAMINATION: 

PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE.

PALLOR-PRESENT.

NO SIGNS OF CLUBBING, ICTERUS, CYANOSIS, LYMPHEDNOPATHY, PEDAL EDEMA

VITALS:

TEMP: 101.5F

PR: 111BPM

BP: 100/70MMHG

GRBS: 102 MG/DL

SPO2: 98 %@RA

RR: 24 CPM

SYSTEMIC EXAMINATION:

CVS: S1, S2 HEARD, NO MURMURS

RS: BAE+, NVS HEARD,BASAL CREPTS +.

PA: DIFFUSE ABDOMINAL TENDERNESS +

CNS : NFAD

PULMONOLGY REFERAL DONE IN/OCAP ?ARDS ADVICE GIVEN: CST 

MONITOR VITALS/ INFORM SOS

OXYGEN INHALATION @ SOS 1-2 LITRES/MINIFSPO2 <92% @ RA WITH NASAL PRONGSSPUTUM FOR C/S : NORMAL ORAL FLORA GROWNURINE C/S : NO GROWTH 

USG:E/O FEW CYSTS NOTED IN RIGHT KIDNEY LARGEST MEASURING 10X10 MM IN MEDULA IN MIDPOLEE/O FEW CYSTS NOTED IN LEFT KIDNEY LARGEST MEASURING 18X12 MM IN

CHANGES

MIDPOLEIMPRESSION: B/L RENAL CYSTSRIGHT GRADE 2 RPD CHANGESLEFT GRADE 3 RPD CHANGES.

INVESTIGATIONS

 


                 PROVISIONAL DIAGNOSIS:

PYREXIA UNDER EVALUATION SECONDARY TO COMMUNITY AQUIRED PNEUMONIA ?ARDS ? PULMONARY KOCHS WITH PRERENAL AKI ON CKD WITH ANEMIA OF CHRONIC DISEASE.

TREATMENT:

                           On 25/10/2023


PYREXIA|EVALUATION? URTI 2° to ? CASP

? PULMONARY KOCHS.

WITH RENAL AKI on CKD. (Stage)

WITH ANAEMIA OF CHRONIC DISEASE

WITH ACID PEPTIC DISEASE


Patient is C/C/C

BP-130/80mmhg

PR-82bpm

CVS- S1S2 heard, no murmurs. 

RS-BAE+,CREPTS-+.

P/A-Soft,Non-Tender.


  1. IV FLUIDS NS, RL ,DNS@ 30 ML/ HR.
  2. INJ.LASIX 20MG/IV/BD.
  3. IN PIPTAZ 2.25 G / IV/ TID
  4. INJ.PAN 40 MG / IV OD
  5. INJ.NEOMOL I G/ IV / SOS
  6. TAB..DOLO650/PO/BD.
  7. TAB NODOSIS 500 MG PO OD
  8. TAB OROFER XT PO OD ( 8PM )
  9. TAB SHELCAL - PO OD
  10. CAP.BIO D3 PO ONCE WEEKLY
  11. INJ.EPO 4000IU/SC/ON E A WEEK.
  12. SYP GRILLINCTUS 15ML PO OD
  13. BETADINE GARGLES + GLASS OF WATER TID
  14. MONITOR VITALS, INFORM SOS
  15. STRICT 1/0 CHARTING.


                       On 26/10/2023

PYREXIA|EVALUATION? URTI 2° to ? CASP

? PULMONARY KOCHS.

WITH RENAL AKI on CKD. (Stage)

WITH ANAEMIA OF CHRONIC DISEASE

WITH ACID PEPTIC DISEASE


Patient is C/C/C

BP-90/6080mmhg

PR-74bpm

CVS- S1S2 heard, no murmurs. 

RS-BAE+,CREPTS-+.

P/A-Soft,Non-Tender.


  1. IV FLUIDS NS, RL ,DNS@ 30 ML/ HR.
  2. INJ.LASIX 20MG/IV/BD.
  3. IN PIPTAZ 2.25 G / IV/ TID
  4. INJ.PAN 40 MG / IV OD
  5. INJ.NEOMOL I G/ IV / SOS
  6. TAB..DOLO650/PO/BD.
  7. TAB NODOSIS 500 MG PO OD
  8. TAB OROFER XT PO OD ( 8PM )
  9. TAB SHELCAL - PO OD
  10. CAP.BIO D3 PO ONCE WEEKLY
  11. INJ.EPO 4000IU/SC/ON E A WEEK.
  12. SYP GRILLINCTUS 15ML PO OD
  13. BETADINE GARGLES + GLASS OF WATER TID
  14. MONITOR VITALS, INFORM SOS
  15. STRICT 1/0 CHARTING.


                        On 27/10/2023


PYREXIA|EVALUATION? URTI 2° to ? CASP

? PULMONARY KOCHS.

WITH RENAL AKI on CKD. (Stage)

WITH ANAEMIA OF CHRONIC DISEASE

WITH ACID PEPTIC DISEASE


Patient is C/C/C

BP-80/50mmhg

PR-73bpm

CVS- S1S2 heard, no murmurs. 

RS-BAE+,CREPTS-+.

P/A-Soft,Non-Tender.


  1. IV FLUIDS NS, RL ,DNS@ 30 ML/ HR.
  2. INJ.LASIX 20MG/IV/BD.
  3. IN PIPTAZ 2.25 G / IV/ TID
  4. INJ.PAN 40 MG / IV OD
  5. INJ.NEOMOL I G/ IV / SOS
  6. TAB..DOLO650/PO/BD.
  7. TAB NODOSIS 500 MG PO OD
  8. TAB OROFER XT PO OD ( 8PM )
  9. TAB SHELCAL - PO OD
  10. CAP.BIO D3 PO ONCE WEEKLY
  11. INJ.EPO 4000IU/SC/ON E A WEEK.
  12. SYP GRILLINCTUS 15ML PO OD
  13. BETADINE GARGLES + GLASS OF WATER TID
  14. MONITOR VITALS, INFORM SOS
  15. STRICT 1/0 CHARTING.


                      On 28/10/2023

 PYREXIA|EVALUATION? URTI 2° to ? CASP

? PULMONARY KOCHS.

WITH RENAL AKI on CKD. (Stage)

WITH ANAEMIA OF CHRONIC DISEASE

WITH ACID PEPTIC DISEASE


Patient is C/C/C

BP-90/60mmhg

PR-74bpm

CVS- S1S2 heard, no murmurs. 

RS-BAE+,CREPTS-+.

P/A-Soft,Non-Tender.


  1. IV FLUIDS NS, RL ,DNS@ 30 ML/ HR.
  2. INJ.LASIX 20MG/IV/BD.
  3. IN PIPTAZ 2.25 G / IV/ TID
  4. INJ.PAN 40 MG / IV OD
  5. INJ.NEOMOL I G/ IV / SOS
  6. TAB..DOLO650/PO/BD.
  7. TAB NODOSIS 500 MG PO OD
  8. TAB OROFER XT PO OD ( 8PM )
  9. TAB SHELCAL - PO OD
  10. CAP.BIO D3 PO ONCE WEEKLY
  11. INJ.EPO 4000IU/SC/ON E A WEEK.
  12. SYP GRILLINCTUS 15ML PO OD
  13. BETADINE GARGLES + GLASS OF WATER TID
  14. MONITOR VITALS, INFORM SOS
  15. STRICT 1/0 CHARTING.


                     On 29/10/2023


PYREXIA|EVALUATION? URTI 2° to ? CASP

? PULMONARY KOCHS.

WITH RENAL AKI on CKD. (Stage)

WITH ANAEMIA OF CHRONIC DISEASE

WITH ACID PEPTIC DISEASE


Patient is C/C/C

BP-90/60mmhg

PR-72bpm

CVS- S1S2 heard, no murmurs. 

RS-BAE+,CREPTS-+.

P/A-Soft,Non-Tender.


  1. IV FLUIDS NS, RL ,DNS@ 30 ML/ HR.
  2. INJ.LASIX 20MG/IV/BD.
  3. IN PIPTAZ 2.25 G / IV/ TID
  4. INJ.PAN 40 MG / IV OD
  5. INJ.NEOMOL I G/ IV / SOS
  6. TAB..DOLO650/PO/BD.
  7. TAB NODOSIS 500 MG PO OD
  8. TAB OROFER XT PO OD ( 8PM )
  9. TAB SHELCAL - PO OD
  10. CAP.BIO D3 PO ONCE WEEKLY
  11. INJ.EPO 4000IU/SC/ON E A WEEK.
  12. SYP GRILLINCTUS 15ML PO OD
  13. BETADINE GARGLES + GLASS OF WATER TID
  14. MONITOR VITALS, INFORM SOS
  15. STRICT 1/0 CHARTING.

 

                           On 30/10/2023

PYREXIA|EVALUATION? URTI 2° to ? CASP

? PULMONARY KOCHS.

WITH RENAL AKI on CKD. (Stage)

WITH ANAEMIA OF CHRONIC DISEASE

WITH ACID PEPTIC DISEASE


Patient is C/C/C

BP-90/60mmhg

PR-74bpm

CVS- S1S2 heard, no murmurs. 

RS-BAE+,CREPTS-+.

P/A-Soft,Non-Tender.


  1. IV FLUIDS NS, RL ,DNS@ 30 ML/ HR.
  2. INJ.LASIX 20MG/IV/BD.
  3. IN PIPTAZ 2.25 G / IV/ TID
  4. INJ.PAN 40 MG / IV OD
  5. INJ.NEOMOL I G/ IV / SOS
  6. TAB..DOLO650/PO/BD.
  7. TAB NODOSIS 500 MG PO OD
  8. TAB OROFER XT PO OD ( 8PM )
  9. TAB SHELCAL - PO OD
  10. CAP.BIO D3 PO ONCE WEEKLY
  11. INJ.EPO 4000IU/SC/ON E A WEEK.
  12. SYP GRILLINCTUS 15ML PO OD
  13. BETADINE GARGLES + GLASS OF WATER TID
  14. MONITOR VITALS, INFORM SOS
  15. SYP.CREMAFFIN 30ml/Po/BD
  16. INJ.CLINDAMYCIN 600MG/IV/BD.

    

                  On 31/10/2023


PYREXIA|EVALUATION? URTI 2° to ? CASP

? PULMONARY KOCHS.

WITH RENAL AKI on CKD. (Stage)

WITH ANAEMIA OF CHRONIC DISEASE

WITH ACID PEPTIC DISEASE

Fever spikes+,Generalised weakness

Patient is C/C/C

BP-90/50mmhg

PR-82bpm

CVS- S1S2 heard, no murmurs. 

RS-BAE+,CREPTS-+.

P/A-Soft,Non-Tender.


  1. IV FLUIDS NS, RL ,DNS@ 50 ML/ HR.
  2. INJ.LASIX 20MG/IV/BD.
  3. IN PIPTAZ 2.25 G / IV/ TID
  4. INJ.PAN 40 MG / IV OD
  5. INJ.NEOMOL I G/ IV / SOS
  6. TAB..DOLO650/PO/BD.
  7. TAB NODOSIS 500 MG PO OD
  8. TAB OROFER XT PO OD ( 8PM )
  9. TAB SHELCAL - PO OD
  10. CAP.BIO D3 PO ONCE WEEKLY
  11. INJ.EPO 4000IU/SC/ON E A WEEK.
  12. SYP GRILLINCTUS 15ML PO OD
  13. BETADINE GARGLES + GLASS OF WATER TID
  14. MONITOR VITALS, INFORM SOS

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