60 YEARS OLD MALE WITH ASCITIC, HYPOPROTIENEMIA,RENAL DYSFUNCTION, with DECREASED URINE OUT PUT


UNIT 2 ADMISSION  (9/3/2021)

DR ASHA KIRAN  (INTERN)
DR  AMULYA  (INTERN)
DR YAMINI (INTERN)
DR JAYANTH (INTERN)
DR PRADEEP (INTERN)
DR VAMSHI (INTERN)
DR ISMAIL (INTERN)

DR PRADEEP  (PG 1ST YEAR  )
DR DIVYA (PG 2ND YEAR)
DR SUFIYA (PG 3RD YEAR)
DR SATISH (PG 3RD YEAR)

DR VIJAYALAXMI ( FACULTY)


A 60 YEARS OLD MALE  CAME  TO CASUALTY WITH COMPLAINTS OF FEVER SINCE  15 DAYS, SOB SINCE  3 DAYS

HISTORY  OF  PRESENT ILLNESS 

PATIENT WAS APPARENTLY ASYMPTOMATIC  BEFORE,
 HE DEVELOPED   FEVER  SINCE 15 DAYS, (HIGH GRADE),INTERMITTENT, NOT ASSOCIATED  WITH CHILLS AND, RELIEVED WITH MEDICATION. 
NO H/O COUGH, NO SPUTUM, COLD, PAIN ABDOMEN 
BURNING MICTURITON +,  INTERMITTENTLY SOB  +,ON EXCERTION  LATER PROGRESSED TO REST  ,
NO ORTHOPNEA, NO PND ,NO CHEST PAIN NO PALPITATIONS, NO PEDAL EDEMA. 
ON /OFF  FACIAL  PUFFINESS  +
?APTHOUS  ULCERS, DIFFICULTY  IN SWALLOWING  .


HISTORY OF PAST ILLNESS 

NOT A K/C/O DM 2, HTN 

NOT A   K/C/O  CAD ,CVA, ASTHAMA, EPILEPSY. 
K/C/O CKD ON CONSERVATIVE  MANAGEMENT 

CHRONIC  SMOKER  AND CHRONIC  ALCOHOLIC STOPPED FROM  3 MONTHS  


GENERAL EXAMINATION 


PATIENT IS CONCIOUS COHERENT COPPERATIVE  ORIENTED TO TIME PLACE AND PERSON 

PALLOR + 
  ICTERUS - VE
CLUBBING, CYANOSIS, PEDAL EDEMA, LYMPHADENOPATHY. (ABSENT)
MALNUTRITION - ABSENT 
DEHYDRATION- ABSENT 

TEMP  - AFEBRILE (99 DEGREE  F)
PULSE RATE - 100BPM
RR - 17  CPM 
BP -  11O/ 100MMHG 
SPO2 - 99% @ROOM AIR 
GRBS- 129MG%

SYSTEMIC EXAMINATION 

CVS - S1 S2 HEARD ,APICAL IMPULSE  6TH,  APEX BEAT 6TH ICS 2CM LATERAL  TO  M L.

RESPIRATORY  SYSTEM-
NVBS IN ALL  LUNG FEILDS,  CHEST  INDRAWING  + 
 B/ L AIR ENTRY PERESNT 


ABDOMEN  - DISTENDED , EVEERTED , TRANSVERSE  SLIT  ,GAURDING  + 
BOWEL SOUNDS HEARD,  
COULDN'T  APPRECIATE  ORGANOMEGALY  , 
SHIFTING DULLNESS  +

CNS

HEIGHER MENTAL FUNCTIONS ARE INTACT 


INVESTIGATION 

HEMOGRAM, CUE  ,RFT, LFT, CHEST  X-RAY M SMEAR  FOR MP , DENGUE  SEROLOGY  , BLOOD CULTURE,  URINE CULTURE,  VIRAL MARKERS (HBSAG, HCV, HIV 1,2)
RBS 





DILATED  SUPERFICIAL ABDOMINAL VEINS













TREATMENT 



UNIT 2 UPDATE

DAY 1 (10/3/21)

S- FEVER SPIKE  + , NOT PASSED STOOLS TODAY MORNING, PASSED FLATUS 

O - PATIENT IS CONCIOIOUS, COHERENT, COPPERATIVE, ORIENTED TO TIME PLACE AND PERSON 
AFEBRILE 
BP 110/100MMHG
PR - 1OO BPM 
ICTERUS-VE
PALLOR- PRESENT 

SYSTEMIC EXAMINATION 
CVS- S1 S2 HEARD, APICAL IMPULSE 6TH ICS 2CM LATERAL TO MCL 
RS- BAE +, NVBS, IN ALL LUNG FEILDS, CHEST INDRAWING +

P/A  - DISTENDED, EVERTED, TRANSVERSE SLIT, GAURDING + BS+ ,COULDN'T APPRECIATE ORGANOMEGALY, SHIFTING DULLNESS +

A
UTI, BPH, K/C/O CKD,  FEVER UNDER EVALUATION, K/C/O CAD


P

TAB  PAN 50MG PO/BD
TAB PCM 500MG PO/SOS
TAB TAMSULOSIN D 0.4/0.5 MG PO/HS
TAB MVT PO/OD
BP, PR, RR, SPO2 MONITORING 
TEMP, I/ O CHARTING 
TEPID SPONGING  SOS 
TAB ECOSPIRIN 75MG PO/OD
TAB CLOPITAB 75MG PO/OD
TAB NITROFURANTOIN 100MG  PO/BD 
TAB AFORVAS 4OMG PO/PO/H/S
TAB LASIX 40MG PO/OD 
ZYTEE GEL FOR L/A 


DAY 2 (11/3/21)

S -  PASSED STOOLS TODAY MORNING, PASSED FLATUS.

O 

PATIENT IS CONCIOUS COHERENT COPPERATIVE, ORIENTED TO TIME PLACE AND PERSON. 

 TEMP-  AFEBRILE 99 DEGREE F 
BP- 16O/100MMHG 
PR - 11O BPM 
RR-29BPM
GRBS- 180MG%
ICTERUS- - VE
PALLOR +VE

CVS- S1 S2 + ,APICAL IMPULSE 6TH ICS
APEX BEAT 6TH ICS, 2CM LATERAL  TO MCL

RR - NVBS IN ALL LUNG FEILDS,  CHEST INDRAWING  + 

P/A - DISTENDED ,EVERTED  ,TRANSVERSE SLIT,  GAURDING + , BS + , COULDN'T  APPRECIATE  ORGANOMEGALY, SHIFTING DULLNESS + 

A
UTI , BPH , FEVER UNDER EVALUATION,  K/C/O CKD ,,KC//O CAD

P
TAB RANTAC 50 MG PO /BD
TAB  PCM 500MG PO/SOS 
TAB  TAMSULOSIN  D  0.4 /0.5 MG PO/HS 
TAB  MVT PO/OD 
BP/PULSE/ RR/SPO2 MONITORING 
TEMP  ,I/O  CHARTING 
TIPID SPONGING SOS 
TAB  ECOSPORIN 75 MG PO /OD 
TAB CLOPITAB  75MG  PO/OD 
TAB NITROFURANTOIN  100 MG PO /BD 
TAB  AFORVAS 4OMG PO /H/S 
TAB LASIX  40MG  PO/OD ( I------X-------X)
ZYTEE  GEL FOR  LOCAL APPLICATION 

 DAY 3 
(12/3/21)

S - FEVER SPIKES PRESENT,  PASSED STOOLS AND FLATUS 

O- PATIENT IS CONCIOIOUS COHERENT COPPERATIVE ORIENTED TO TIME PLACE AND PERSON 
BP  11O/ 100 MMHG 
PR  1OO BPM 
GRBS- 102 MG %
APICAL IMPULSE 6TH ICS, APEX BEAT 6TH ICS LATERAL TO MCL 
RS  B/L AIR ENTRY PERESNT 
PER ABDOMEN  SOFT, DISTENDED, SHIFTING DULLNESS +BOWEL SOUNDS HEARD 

A - UTI  , K/C/O CKD, FEVER UNDER EVALUATION,  K/ /O CAD,? GRADE  1 HYPERTENSIVE 

P

TAB  PCM 500MG PO/TID  
TAB RANTAC 50 MG PO/BD 
TAB TAMSULOSIN D  0.4 MG PO  H/S 
TAB ECOSPIRIN-75MG PO /OD
TAB CLOPIDOGREL 75MG  PO/OD 
TAB NITROFURANTOIN  1OO MG PO/TID 
TAB ATORVAS 40MG PO H/S
TAB MVT  PO/OD 
TAB LASIX 40MG PO/OD
ZYTEE GEL FOR LOCAL APPLICATION 
BP, PR, RR SP02  MONITORING 
I/O CHARTING 
TIPID SPONGING 
SYP CITRALKA 15 ML IN GLASS OF WATER  TID
TAB OROFER XT  OD
INJ VITCOFOL  100MG /2.CC IM /OD
SYP LACULOSE  15ML /TID 
FLUID RESTRICTION UPTO  1 LIT PER DAY


13/3/21

S 
DECREASED  APPETITE,  DECREASED URINE OUT PUT,  PASSED STOOLS IN CLOTHES  (4 EPISODES)

FEVER SPIKES PRESENT  

O 
PATIENT IS CONCIOUS COHERENT COPPERATIVE ORIENTED TO TIME PLACE AND PERSON 

BP 120/80 MMHG
PR  98BPM
RR 23CPM 
SPO2  98% 
CVS - S1 S2 HEARD,  APICAL IMPULSE 6TH ICS 
RS B/L AIR ENTRY PERESNT 
P/A SOFT NON TENDER,  SHIFTING DULLNESS PRESENT 

A 
UTI , K/C/O CKD ,CAD , GRADE 1 HYPERTENSIVE 

P 

TAB PCM 500MG PO / OD 
TAB RANTAC  50 MG PO/ BD 
TAB NITROFURANTOIN  1OO MG/ PO/ TID
TAB  AFORVAS  4OMG PO  H/S 
TAB  MVT PO / OD 
TAB OROFER  XT OD 
INJ VITCOFOL  1OO MG  / 2 CC / OD 
TAB LASIX 40MG PO  /OD 
SYP  CITRALKA 15 ML IN GLASS OF WATER  TID 
ZYTEE GEL FOR LOCAL APPLICATION 
SYP LACULOSE  5ML OD 
INJ VIT K 10MG  IV OD 
TAB SHELCAL PO OD 


DAY 4 ( 14/3/21)

S 
DECREASED APPETITE, FEVER SPIKES PRESENT,  DECREASED URINE OUT PUT,  LOOSE STOOLS SUBSIDED 

O 
PATIENT IS CONCIOUS COHERENT COPPERATIVE ORIENTED TO TIME PLACE AND PERSON 
AFEBRILE 
BP 12O/ 80 MMHG 
PR 102  BPM 
SPO2 97%
CVS S1 S2 HEARD 
RS BL AIR ENTRY PERESNT 
CNS NFD 
PER ABDOMEN  - SOFT NON TENDER, SHIFTING DULLNESS PRESENT 

A 

UTI,  K/C/O CKD, CAD,  GRADE 1 HYPERTENSIVE ENCEPHALOPATHY 

P 

TAB PCM  500MG PO  /TID
TAB RANTAC  50MG PO / BD 
TAN NITROFURANTOIN  100MG  PO /TID
TAB ATORVAS 40MG  PO H/S
TAB MVT PO OD 
TAB OROFER  XT PO BD
INJ VITCOFOL  1000MCG 2CC OD 
TAB LASIX  40MG  PO OD 
SYP CITRALKA  15ML IN GLASS OF WATER  TID
ZYTEE GEL FOR LOCAL APPLICATION 
INJ VIT K 10MG IV OD 
 SYP LACULOSE 5ML PO OD
TA  SHELCAL  PO OD
TIPID SPONGING 

DAY 5
15/3/21

S
 DECREASED APPETITE,  DECREASED URINE OUT PUT, FEVER SPIKES PRESENT,  I/O 1000ML / 600ML 

O 

PATIENT IS CONCIOUS COHERENT COPPERATIVE ORIENTED TO TIME PLACE AND PERSON 
BP 11O/80 MMHG  
PR 107 BPM 
CVS S1 S2 HEARD 
RS B/L AIR ENTRY PERESNT 
CNS NO FOCAL DEFICIT 
P/A SOFT NON TENDER, DISTENDED 


A
UTI  , K/C/O CKD CAD , GRADE 1 HYPERTENSIVE,  HEPATIC ENCEPHALOPATHY 


P

TAB PCM  500MG  PO TID 
TAB RANTAC  50MG  PO BD 
TAB NITROFURANTOIN  100MG  PO TID 
TAB AFORVAS 4OMG  PO H/S
TAB MVT  PO OD 
TAB OROFER  XT PO BD 
INJ VITCOFOL  1000MCG /2CC /OD
INJ LASIX  40MG  PO OD 
SYP CITRALKA  15ML  IN GLASS OF WATER  
INJ VIT K  10MG  IV OD 
SYP LACULOSE  5 ML PO OD 
TAB SHELCAL  PO OD 
INJ ERYTHROMYCIN  4000IU S/C BD
SYP APTIVATE  10 ML TID 



DAY 6 16/3/21









DAY  8( 18/3/21)



DAY 9N( 19/3/21)


DEATH. SUMMARY 

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