A 73YR OLD FEMALE CAME WITH COMPLAINTS OF BREATHLESSNESS

A 73YR OLD FEMALE

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 

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 HISTORYK/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 ADVISEDSYRUP 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 ADVISEDINJ PAN 4GM IV TID

 URO REFFERAL WAS DONE I/V/O LEFT HYDROURETERONEPHROSIS ON26/03/24 ADVISEDNCCT KUB AND REVIEW WITH SERUM CREATININE AND BLOOD UREA 

REVIEW URO REFFERAL WAS DONE ON 29/03/24ADVISED- SYRUP ALKASTONE B6 15ML IN 100ML OF WATER TWICE DAILY 


Investigations:
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 145136 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 145136 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 0.20.0 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: IMPRESSION        
LEFT URETERIC CALCULUS LEFT MODERATE HYDROURETERONEPHROSIS CHOLELITHIASIS USG DONE ON 25/3/24IMPRESSIONCHOLELITHIASIS LEFT KIDNEY SHOWS RAISED ECHOGENECITY WITH FOCAL CALIECTASIS AND HYDROURETERO NEPHROSIS 2D ECHO DONE ON 25/03/24NO 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


 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                     
DISCHARGE SUMMARY:
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 

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 HISTORYK/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 ADVISEDSYRUP 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 ADVISEDINJ PAN 4GM IV TID

 URO REFFERAL WAS DONE I/V/O LEFT HYDROURETERONEPHROSIS ON26/03/24 ADVISEDNCCT KUB AND REVIEW WITH SERUM CREATININE AND BLOOD UREA 

REVIEW URO REFFERAL WAS DONE ON 29/03/24ADVISED- SYRUP ALKASTONE B6 15ML IN 100ML OF WATER TWICE DAILY 


Investigations:
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 145136 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 145136 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 0.20.0 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: IMPRESSION        
LEFT URETERIC CALCULUS LEFT MODERATE HYDROURETERONEPHROSIS CHOLELITHIASIS USG DONE ON 25/3/24IMPRESSIONCHOLELITHIASIS LEFT KIDNEY SHOWS RAISED ECHOGENECITY WITH FOCAL CALIECTASIS AND HYDROURETERO NEPHROSIS 2D ECHO DONE ON 25/03/24NO 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


 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                     

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