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1. DPT OF INTERNAL MEDICINE
MORNINIG SESSION

2.  IDENTIFICATION  DATE OF ADMISSION  23/2/15
 Age  50
 SEX F
 MRN  705703
 Address
 Admission
Diagnosis
P1=SCAP (Multifocal Pneumonia)
P2=Sepsis of Chest Focus
P3=AKI (? Septic ATN)
P4=Moderate Anemia 2ndry to ? IDA
HU CHMS SOM Dpt of Internal medicine 2
2/12/2024

3. Subjective Evidence
HPI
HU CHMS SOM Dpt of Internal medicine 3
2/12/2024

4. Objective Evidence
4
GA ASL
V/S
BP = 96/66 PR =110
RR = 26 T0 = 36.2
SPO2 = 92 on INo2
HEENT Pale conjuctiva & NIS
LG No LAP
RS
Decreased air entry over lower 2/3 of posterior chest Bilateraly
Coarse crackle over Rt lower 1/3 and Lt lower 2/3 lung field
CVS
S1 & S2 well heard
No murmur
No gallop

5. Objective Evidence
5
Abdomen
Flat abdomen moves with respiration
No Tenderness
No organomegaly
No signs of fluid collection
GUS No CVAT
MSK No edema
IGS No palmar palor
CNS GCS 15/15

6. Complete blood count Clinical Chemistry
Test Item Result Ref Range Test Item Result Ref range
WBC 15.7 N,78.L,9.7=17
N,87 L,6.6
4.0-11x103/L FBS/RBS 174 75-100 mg/dl
RBC 4.0-5.6X1012/L Creatinine 0.6 =2.4 0.5-1.2 mg/dl
HCT 28 =22 36-46% Urea 13-43 mg/dl
HGB 9.8g/Dl =7.9 12-16g/dl SGOT 76 12-38 U/L
MCV 71fl =71 80-100fl SGPT 27 7-41 U/L
Billirubin T 0.64 <1.2 mg/dl
Billirubin D 0.1 <0.4 mg/dl
HbA1C
MCH 27-33 pg Serum E Result GENE Xpert
MTB not Detected
RDW 18 =19 <14.5% Na 136
latelets 318X10^3 =268 <150-450x10-9/L K 4.2
SR 100 0-20mm/hr. Cl 95
Lipid profile Urine ANALYSIS
holestrol WBC 2-3/HPF
rigliceride RBC 0-2/HPF
DH Albumin Negative
6

7. CXR
2/12/2024 HU CHMS SOM Dpt of Internal medicine 7

8. • ECG
2/12/2024 HU CHMS SOM Dpt of Internal medicine 8
IMAGINGS

9. What was done
 Put on INo2 at 1L/min
 Ceftriaxone 1g IV BID
 Vancomycine 750mg iv daily
 PCM 1g po prn
 Put on MF
 Follow v/s clossely
HU CHMS SOM Dpt of Internal medicine 9
2/12/2024

10. PLAN
• Do Blood Culture
• Repeat Gene Xpert
2/12/2024 HU CHMS SOM Dpt of Internal medicine 10