A 50-year-old female presented with multifocal pneumonia, sepsis, acute kidney injury, and anemia. On examination, she had decreased breath sounds and crackles bilaterally. Laboratory tests showed leukocytosis, elevated creatinine and urea, and normal chest x-ray and ECG. She was started on oxygen, antibiotics, and monitoring of vital signs. Further tests planned included repeat blood cultures and Gene Xpert to identify the causative organism.

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