70 yr old female case of htn 10 yr.on off medicine.Now 10 days back she had fever associated dry cough ,lac of appetite, generalised weakness in lower limb,low urine output.on examination chest bilateral crepts lower zone more on ryt side,no paddle edema,liver spleen no tenderness,jvp mild raised.Today temp normal,bp 170/100.spo2 94,HR 78.diagnose nd line of treatment.

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CBC raised WBC 15000 Urea 86 Creat 4.57 CXR Rt apical rounded heziness? Fungal ball ? Fibrocavitary lesion in Rt midzone Diffuse fibrocyctic lesions R>L Concavity of Rt border of heart suggests RVH Lt paracardiac heziness Cardiomegaly Paresis of lower limbs probably due to hyperkalaemia LFT, AG ratio, eGFR, Electrolytes, Lipid profile Urine for RE Renal colour doppler USG of whole abdomen ECG 2D echo Sputum for CS, CBNAAT Serum Anti Aspergillus antigen CKD with Chest infection with HTN with Rt ventricular failure with dyselectrolytaemia Inj Ceftrioxone 1gm IV bd×7days Bronchodilator Mucolytes Duolin inhaler PCM ACE blocker as Ramipril 5mg od Diuretics Dytor 20 mg daily morning Water & fluid intake not more than 1.5 lit Further see reports & manage accordingly.

Present complaints are related to infection as tlc is iver 15000 Bul and sr creatinine are raised with low urine out put suggest pre renal or renal failure Mild basal crepts with raised jvp and high bp reflects Rhf With these findings it is necessary to go for urine routine sr electrolytes ecg Xray chest is not clear but except cardiomegaly nothing else can be makeout Rx as pt is kco htn and having bp 170/100 Control with telmisartan and diuretics To increase urine output keep pt on iv fluids and inj lasix so far satisfactory output is seen if output does not increases than usg abd and ivp or renal doppler to r/o renal damage it may require peritoneal or renal dialysis Add broadspectrum antibiotics to control the infection like inj Ceftriaxozone As pt is aged and noncompliant ofhtn vigrous monitoring will be required

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Fever, cough, bilateral crepts and raised WBC count indicate chest infection SpO2 94 indicate that she needs oxygen support Creatinine of 4.51 with BUN of 86 Bun creatinine ratio of 19 indicate prerenal type of renal failure She needs appropriate IV antibiotics Ceftriaxone 1 gm twice a day would be a good choice as it do not require adjustment of dose for renal failure Central venous Line with CVP monitoring Hydration to ensure CVP of more than 8 Treatment of hypertension with calcium channel blocker and beta blocker

URINE exam report is required . ECG ,ECHO , ELECTROLYTES, SUGARS , AVG needed. Probable diagnosis--HTN,CKD / ACUTE RENAL SHUTDOWN due urosepsis, cardiac failure, pulmonary edema Suggested-- Antibiotics, diuretics, judicious fluid administration, salt and electrolyte balance, and renal and cardiac support .

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Creatinine and BUL raised with low urine output shows acute renal failure X-ray shows parahilar hazzines with lower lobe of both lungs Pneumonitic patch Cardiomegaly with pneumonia Wbc raised shows supradded bacterial infection Bp raised, and jvp raised, suggest RHF Normal down bp with ACE inhibitors and diuretics Broad spectrum antibiotics like Ceftriaxone sulbactum and amikacin Controlled hydration Get 2D echo, usg abdomen, KUB

Would Amikacin be safe keeping in view elevated level be creatinine ie 4.5
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WBC is high. Chronic kidney failure Cardiomegaly Nephrologist opinion for. H. Dialasis.

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Berberis Aqua and Cantharis can give improvement.

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