Cases 1-16

 

Case 1

https://himajav.blogspot.com/2023/08/53f-metabolic-syndrome.html

53 year old female housewife by occupation resident of coochbihar admitted with complains of generalised weakness since 6 years

The patient's medical history reveals that she was asymptomatic until six years ago when she presented with weight loss, xerostomia, and anorexia. She sought medical attention at a local medical facility, where she was diagnosed with Diabetes mellitus and subsequently initiated on oral hypoglycemic agents.

Around four years ago, the patient began experiencing generalized asthenia and easy fatigability, leading to the diagnosis of both Hypertension and hypothyroidism.

Approximately four years ago, the patient complained of cervical discomfort, prompting a diagnostic consideration of cervical spondylosis. This condition was managed with a course of physiotherapy.

Currently, the patient reports intermittent occurrences of generalized asthenia, easy fatigability, and xerostomia. She also experiences sporadic episodes of lumbosacral discomfort and bilateral coxalgia, which intensify during prolonged periods of sitting.

Furthermore, the patient describes sporadic episodes of burning epigastric discomfort, which is alleviated by food ingestion or resolves spontaneously after a certain period. She occasionally experiences early morning nausea that subsides after breakfast.

Sleep disturbances are also reported, with frequent nocturnal awakenings disrupting the patient's sleep pattern.

Lastly, the patient presents with sporadic bilateral lower limb paresthesias, without specific exacerbating or relieving factors.

PSYCHOSOCIAL HISTORY

Raised in a rural environment as part of a nuclear family, she pursued her education up to the 10th grade. However, societal norms prevalent in her village led her to discontinue her studies thereafter.

Subsequently, she immersed herself in domestic duties. At 26, she married a businessman. Following their union, she conceived naturally and gave birth to a son within the first year. Opting to concentrate fully on her young child, she elected to terminate her pregnancy a year later.

Around 6 to 7 years later, she conceived once again, only to experience a miscarriage. This incident weighed on her for months, yet the support of her family aided in her recovery.

Currently, she enjoys a harmonious nuclear family life with her husband, son, and daughter-in-law. Her son actively participates in their hardware store business, while her daughter-in-law works as a school teacher.

Initially, she managed household duties independently. However, in recent years, she has faced increasing fatigue and weakness. With her daughter-in-law's teaching commitments, she sought the help of a maid for household tasks.

Her daily routine involves waking up at 6:30 am, engaging in chores, enjoying tea with biscuits, preparing meals, and spending quality time with family. Due to her diabetes diagnosis, she shifted from consuming rice for dinner to eating chapati.

Despite her talkative and proactive nature, she's been battling fatigue for 4-5 years, which has left her dissatisfied. Health issues in her husband and daughter-in-law, alongside her own medical regimen, have become a concern despite financial stability.

She experiences heightened anxiety over minor matters and constantly worries about her health. Her sleep patterns are erratic, with occasional full-night sleep but often interrupted rest.

PAST HISTORY

Known case of Diabetes since 6 years

Initially on tab glycomet 500mg now changed to tab vildgliptin and metformin 50/500mg po/Od

Known case of Hypertension since 4 years

On tab telmasartan 40mg but doesn’t take it regularly 

Known case of Hypothyroidism 

Initially on T Thyroxine 25mcg for 2 years and increased to 50mcg

Now on T thyroxine 32.5mcg

Had cataract surgery to right eye

PERSONAL HISTORY

no smoking/alcohol history

Consumes Areca nut/ pan two per day

General examination

Height : 5’4

Body weight: 67kgs

Mid arm circumference: 25cms

Abdominal circumference: 90cms

BP : 130/80mmhg

PR : 75bpm

GRBS : 

Temp: afebrile

No pallor, icterus,cyanosis, clubbing, lymphadenopathy, edema

SYSTEMIC EXAMINATION

Cardiovascular system:

S1 and S2 heard no murmurs heard 

Central nervous system: 

No focal neurological deficit, cranial nerve intact

Respiratory system:Bilateral air entry-present ,Normal vesicular breath sounds-heard

Abdominal examination: soft and non tender, No Hepatomegaly, spleen is not palpable.

PROVISIONAL DIAGNOSIS 

Metabolic syndrome with known case of DM,HTN and Hypothyroidism 

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect current best evidence based input

This Elog also reflects my patient centered online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan

Thankyou Dr Stimita for helping in History

53 year old female housewife by occupation resident of coochbihar admitted with complains of generalised weakness since 6 years

The patient's medical history reveals that she was asymptomatic until six years ago when she presented with weight loss, xerostomia, and anorexia. She sought medical attention at a local medical facility, where she was diagnosed with Diabetes mellitus and subsequently initiated on oral hypoglycemic agents.

Around four years ago, the patient began experiencing generalized asthenia and easy fatigability, leading to the diagnosis of both Hypertension and hypothyroidism.

Approximately four years ago, the patient complained of cervical discomfort, prompting a diagnostic consideration of cervical spondylosis. This condition was managed with a course of physiotherapy.

Currently, the patient reports intermittent occurrences of generalized asthenia, easy fatigability, and xerostomia. She also experiences sporadic episodes of lumbosacral discomfort and bilateral coxalgia, which intensify during prolonged periods of sitting.

Furthermore, the patient describes sporadic episodes of burning epigastric discomfort, which is alleviated by food ingestion or resolves spontaneously after a certain period. She occasionally experiences early morning nausea that subsides after breakfast.

Sleep disturbances are also reported, with frequent nocturnal awakenings disrupting the patient's sleep pattern.

Lastly, the patient presents with sporadic bilateral lower limb paresthesias, without specific exacerbating or relieving factors.

PSYCHOSOCIAL HISTORY

Raised in a rural environment as part of a nuclear family, she pursued her education up to the 10th grade. However, societal norms prevalent in her village led her to discontinue her studies thereafter.

Subsequently, she immersed herself in domestic duties. At 26, she married a businessman. Following their union, she conceived naturally and gave birth to a son within the first year. Opting to concentrate fully on her young child, she elected to terminate her pregnancy a year later.

Around 6 to 7 years later, she conceived once again, only to experience a miscarriage. This incident weighed on her for months, yet the support of her family aided in her recovery.

Currently, she enjoys a harmonious nuclear family life with her husband, son, and daughter-in-law. Her son actively participates in their hardware store business, while her daughter-in-law works as a school teacher.

Initially, she managed household duties independently. However, in recent years, she has faced increasing fatigue and weakness. With her daughter-in-law's teaching commitments, she sought the help of a maid for household tasks.

Her daily routine involves waking up at 6:30 am, engaging in chores, enjoying tea with biscuits, preparing meals, and spending quality time with family. Due to her diabetes diagnosis, she shifted from consuming rice for dinner to eating chapati.

Despite her talkative and proactive nature, she's been battling fatigue for 4-5 years, which has left her dissatisfied. Health issues in her husband and daughter-in-law, alongside her own medical regimen, have become a concern despite financial stability.

She experiences heightened anxiety over minor matters and constantly worries about her health. Her sleep patterns are erratic, with occasional full-night sleep but often interrupted rest.

PAST HISTORY

Known case of Diabetes since 6 years

Initially on tab glycomet 500mg now changed to tab vildgliptin and metformin 50/500mg po/Od

Known case of Hypertension since 4 years

On tab telmasartan 40mg but doesn’t take it regularly 

Known case of Hypothyroidism 

Initially on T Thyroxine 25mcg for 2 years and increased to 50mcg

Now on T thyroxine 32.5mcg

Had cataract surgery to right eye

PERSONAL HISTORY

no smoking/alcohol history

Consumes Areca nut/ pan two per day

General examination

Height : 5’4

Body weight: 67kgs

Mid arm circumference: 25cms

Abdominal circumference: 90cms

BP : 130/80mmhg

PR : 75bpm

GRBS : 

Temp: afebrile

No pallor, icterus,cyanosis, clubbing, lymphadenopathy, edema

SYSTEMIC EXAMINATION

Cardiovascular system:

S1 and S2 heard no murmurs heard 

Central nervous system: 

No focal neurological deficit, cranial nerve intact

Respiratory system:Bilateral air entry-present ,Normal vesicular breath sounds-heard

Abdominal examination: soft and non tender, No Hepatomegaly, spleen is not palpable.

Clinical images

PROVISIONAL DIAGNOSIS 

Metabolic syndrome with known case of DM,HTN and Hypothyroidism 

INVESTIGATIONS

USG ABDOMEN

GRADE 2 fatty liver

HEMOGRAM

HB - 10.9gm/dl

TLC- 8000 cells/cumm

N/L/E/B- 57/34/7/0

PCV - 33.4 vol%

MCV- 91.0 fl 

MCH- 29.7 pg

MCHC- 32.6 %

RDW-CV - 14.1%

RDW-SD - 47.8 fl

RBC- 3.67 millions/cumm

PLATELETS- 2.5lakhs/cumm

CUR

COLOUR- pale yellow

Appearance- clear

Reaction- acidic

SP gravity- 1.010

ALBUMIN- NIL

SUGAR- NIL

BILE SALTS- NIL

BILE PUGMENTS- NIL

PUS CELLS - 2-4

EPITHELIAL CELLS- 2-3

RBC - NIL

CRYSTALS- NIL

CASTS- NIL

AMORPHOUS DEPOSITS - NIL

THYROID PROFILE

T3 - 1.25 ng/ml

T4 - 11.68 micro g/dl

TSH - 7.35 micro iu/ml

FBS 135mg/dl

PPBS

HBA1C

LIPID PROFILE

Total cholesterol - 211mg/dl

Triglycerides- 106mg/dl

HDL- 43.1mg/dl

LDL-113 mg/dl

VLDL-21.2mg/dl

RFT

UREA - 31mg/dl

CREATININE- 0.8mg/dl

URIC ACID-5.7mg/dl

CALCIUM- 10.0mg/dl

PHOSPHORUS-3.1mg/dl

SODIUM- 144meq/L

POTASSIUM - 4.4 mEq/L

CHLORIDE- 99 mEq/L

DIAGNOSIS

METABOLIC SYNDROME 

ALLERGIC CONTACT DERMATITIS 

IMMATURE SENILE CATARACT IN BOTH EYES

OTITIS EXTERNA in right ear

Treatment 

Adviced cataract surgery by Opthal dept 

Mupirocin ointment for application in external ear - adviced by ENT for otitis externa

Treatment adviced by DVL for allergic contact dermatitis 

Tab Teczine po/Od for one week

Momate F cream for local application for one week

Venusa max lotion for local application for two weeks

Lifestyle modifications 

Physical activity 30mins everyday

Tab vildagliptin and metformin 50/500mg po/Od

Tab telmasartan 40mg po/Od

Tab thyroxine 32.5mcg po/od

Follow up in PaJR

After going home 

First Encounter: 08/05/2023

• Outcome: Ongoing management of metabolic syndrome with stabilization.

Case 2

https://himajav.blogspot.com/2023/08/72m-cidp-3years.html

An 80-year-old male resident of Kamanpet was admitted with complaints of acute urinary and fecal retention for the past 24 hours. The patient had been in a stable condition until a month ago when he began experiencing bilateral lower limb and knee pain. He sought care at a local hospital and received conservative management. During this time, he was informed about the risk of kidney injury and advised to follow a renal diet.

Yesterday, the patient experienced an inability to defecate (accompanied by the absence of flatus) and urinate, along with shortness of breath. There is no history of fever, but the patient did report constipation two days ago. 

PAST HISTORY

 known case of hypertension for the past 10 Years and has been diagnosed with diabetes mellitus for the past 6 years.

PaJR conversation 

This Elog also reflects my patient centered online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan

PRESENT HISTORY

An 80-year-old male resident of Kamanpet was admitted with complaints of acute urinary and fecal retention for the past 24 hours. The patient had been in a stable condition until a month ago when he began experiencing bilateral lower limb and knee pain. He sought care at a local hospital and received conservative management. During this time, he was informed about the risk of kidney injury and advised to follow a renal diet.

Yesterday, the patient experienced an inability to defecate (accompanied by the absence of flatus) and urinate, along with shortness of breath. There is no history of fever, but the patient did report constipation two days ago. 

PAST HISTORY

 known case of hypertension for the past 10 Years and has been diagnosed with diabetes mellitus for the past 6 years.

GENERAL EXAMINATION

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema

BP-110/70mmhg

PR - 70bpm

GRBS

Spo2-98% at RA

CVS- s1s2 heard, no murmur

R/S- BAE present, NVBS

P/A- Soft,NT

CNS- NFND

P/R : No anal tags, Anal fissure noted in 6’o clock posistion and No fistula

Anal tone decreased

Glove stained with stool 

CLINICAL IMAGES





PROVISIONAL DIAGNOSIS

AKI WITH ?DIABETIC NEPHROPATHY

TYPE 2DM and HTN

INVESTIGATIONS

                                    

HB - 10.7gm/dl.                          —>   12gm/dl 

TLC- 12,200 cells/cumm.           —>  11,100

PLATELETS- 2.75lakhs/cumm. —> 2.8

24/08/2024

HB - 9.2gm/dl

TLC- 27000 cells/cumm

PLATELETS- 2.09lakhs/cumm

CUE

COLOUR- pale yellow

Appearance- clear

Reaction- acidic

SP gravity- 1.010

ALBUMIN- +

SUGAR- ++

BILE SALTS- NIL

BILE PUGMENTS- NIL

PUS CELLS - 2-4

EPITHELIAL CELLS- 2-3

RBC - NIL

CRYSTALS- NIL

CASTS- NIL

AMORPHOUS DEPOSITS - NIL

FBS-107

PLBS-197

HBA1C-6.7

Serum osmalality - 247 mOSM/kg

URINARY ELECTROLYTES

SODIUM  - 108

POTASSIUM-9.73

CHLORIDE-153

SPOT UPCR

URINE PROTEIN - 13.6

CREATININE-28.0

RATIO- 0.48

RFT

UREA - 66mg/dl.                  58mg/dl.  54mg/dl.   66

CREATININE- 2.78mg/dl.   2.2mg/dl.  2.7mg/dl. 3.0

URIC ACID-6.1mg/dl.         5.3mg/dl.  5.2mg/dl. 5.4

CALCIUM- 9.4mg/dl.          10mg/dl.  9.9mg/dl.  9.6

SODIUM- 128meq/L.              126mEq/L. 133mEq/L 134

POTASSIUM - 4.4 mEq/L.       4.3mEq/L. 5.0mEq/L. 4.9

CHLORIDE- 92mEq/L.            93mEq/L. 91mEq/L. 97

LFT

TOTAL BILIRUBIN - 0.82

DIRECT BILIRUBIN - 0.18

AST -23

Alt-20

ALP-212

TOTAL PROTEINS-5.0

ALBUMIN-3.0

A/G-1.70

ABG

PH -7.4

Pco2- 26.8

Po2- 103

Hco3-16.7

Interpretation: primary respiratory alkalosis acute with secondary metabolic acidosis

ECG



CHEST X-RAY



ERECT ABDOMEN X RAY



USG ABDOMEN

Right Renal calculi e/o 6mm in the mid pole of right kidney

Right Hydrouretronephrosis 

Left complex Renal cortical cysts

Grade 1 RPD changes in bilateral kidneys

2D ECHO

EF 64%

IVC Size (1.09cms) collapsing

Moderate to severe MR (eccentric MR) Mild AR/TR with PAH

No RWMA

No AS/MS, sclerotic AV

Good LV systolic function

No diastolic dysfunction, No PE

REVIEW 2D ECHO ON 23-08-2023

No RWMA

IVC 1.45cms Non collapsing 

RVSP= 42+10=52mmhg

PML PROLAPSE

Moderate to severe MR (eccentric MR) moderate AR  mild to moderate TR with PAH

No AS/MS, sclerotic AV

Good LV systolic function

 diastolic dysfunction present,No PE

UROLOGY REFERAL





Surgery Referal 





CONVERSATIONAL DECISION SUPPORT SYSTEM (CDSS)

[19/08/23, 11:23:45] ✍🏼: Fecal and urinary retention

1. What are the potential causes of simultaneous acute urinary and fecal retention in an elderly patient?

2. Are there any neurological, structural, or obstructive factors contributing to the retention of both urine and feces?

Shortness of Breath:

1. How does the presence of shortness of breath correlate with the patient’s inability to defecate and urinate?

2. Could there be a cardiovascular or respiratory issue causing both the shortness of breath and the urinary/fecal retention?

3. What diagnostic tests can help differentiate between cardiopulmonary and other potential causes of shortness of breath in this context?

[24/08/23, 19:00:10] Rakesh Biswas Sir HOD GEN MED: Great questions 👏

[24/08/23, 19:02:15] Rakesh Biswas Sir HOD GEN MED: What is thw connection between heart failure and intestinal dysmotility? 

Review the literature and share. We have reviewed this in the past

[24/08/23, 19:16:49] ✍🏼: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5924849/

Although constipation represents the most common clinical manifestation of colon dysmotility in critically ill patients, colon dysmotility in these patients may rarely present in the form of acute pseudo-obstruction. Acute pseudo-obstruction (ACPO), also referred to as Ogilvie’s syndrome, is defined as a clinical syndrome characterized by impairment of intestinal propulsion, which may bear a resemblance to intestinal obstruction, in the absence of a mechanical cause. Acute intestinal pseudo-obstruction may also involve the small intestine and most frequently occurs in patients with stroke, myocardial infarction, peritonitis, sepsis, and postoperatively in orthopedic surgery, cesarean section, cardiovascular or lung surgery [61-63]. The pathophysiology underlying ACPO remains rather unclear, with the prevailing hypothesis being an imbalance in colonic autonomic innervation in the setting of other predisposing factors. The clinical hallmark of ACPO is the presence of dilation of the colon on a plain radiograph. The dilation favorably involves the cecum and the ascending and transverse colon, although the left colon, including the rectum, may also be affected. The prognosis of acute intestinal pseudo-obstruction varies with the underlying clinical condition.

[24/08/23, 20:17:50] ✍🏼: Is our patient having pseudobstruction as you said sir?



[24/08/23, 20:18:19] Rakesh Biswas Sir HOD GEN MED: Do they have a reference for the last three statements here or is their clinical opinion?

[24/08/23, 20:19:03] Rakesh Biswas Sir HOD GEN MED: Shows good amount of dilatation

Update about the patient after going on lama from our hospital

[25/08/23, 17:21:42] ✍🏼: The patient was admitted in NIMS Hyderabad 

Patient was kept in ICU and the doctors haven’t discussed anything yet with the patient attenders

[25/08/23, 17:28:27] Rakesh Biswas Sir: Find out from @919505766290 's or anyone else's contacts in NIMs

[26/08/23, 14:57:10] ✍🏼: Update: Doctors are planning for kidney stent placement tomorrow morning

[26/08/23, 14:58:59] Rakesh Biswas Sir: What about his heart failure and intestinal distension symptoms?

[26/08/23, 14:59:15] ✍🏼: They are still there sir

[26/08/23, 15:02:15] Rakesh Biswas Sir: What acute damage was the hydronephrosis doing now that couldn't have waited? 

@919604701505 This reminds me of the discussion in the other group about how it would have helped the primary care physician to meddle in and optimize the complexity in the patient's care who is currently being handled by the device and drug driven industrial medical training!

[26/08/23, 15:03:16] ✍🏼: They are currently focusing on getting the infection /sepsis under control sir

[26/08/23, 15:04:43] Rakesh Biswas Sir: How? Do they think the urinary obstruction is causing the sepsis? Did we grow any organism?

[30/08/23, 16:30:29] ✍🏼: Patient will get discharged tomorrow from NIMS sir

The patient is doing fine like before and Symptomatically also better.

[30/08/23, 16:35:24] Rakesh Biswas Sir: Will be looking forward to know the details from their discharge summary

[03/09/23, 22:44:34] Rakesh Biswas Sir: Even we had done the CT abdomen here? 

Please share our discharge summary also to join the dots

[03/09/23, 22:53:58] ✍🏼: No sir we haven’t done the CT here

[09/09/23, 18:29:30] Rakesh Biswas Sir: Done in NIMs? Reason?

[09/09/23, 18:30:03] ✍🏼: KIMS Sir

Krishna institute of medical sciences

[09/09/23, 18:30:17] ✍🏼: Known case of ckd

[09/09/23, 18:44:48] Rakesh Biswas Sir: Why total carbon dioxide?

[09/09/23, 18:45:06] Rakesh Biswas Sir: From NIMs to KIMS? Any reason?

[09/09/23, 20:25:29] ✍🏼: No sir I mistook Kim’s as nims in phone call but later when he shared his discharge summary then realised it is Kim’s

[28/03/24, 19:41:59] Rakesh Biswas Sir: Any update? 

[28/03/24, 19:50:36] ✍🏼: Patient expired due to cardiac arrest 6 days ago sir

Discharge summary

Diagnosis

UROSEPSIS SECONDARY TO RENAL CALCULI , HEART FAILURE WITH PRESERVED EJECTION FRACTION (EF 64%) ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE WITH DIABETIC NEPHROPATHY WITH POST RENAL AKI , PARTIAL PHIMOSIS ; RIGHT HYDROURETERONEPHROSIS WITH PROSTATOMEGALY WITH TRUE HYPONATREMIA(RESOLVING) SECONDARY TO ?DEHYDRATION , OSTEOARTHRITIS OF B/L KNEE (HYPERTENSION AND TYPE2 DIABETES).

Case History and Clinical Findings

COMPLAINTS OF SOB SINCE 2DAYS AND CONSTIPATION AND UNABLE TO PASS URINE SINCE 2 DAYS

HOPI :

PATIENT IS APPARENTLY ASYMPTOMATIC 2DAYS BACK THEN HE DEVELOPED CONSTIPATION AND UNABLE TO PASS URINE WHICH WAS INSIDIOUS IN ONSETAND UNABLE TO PASS FLATUS SINCE 1DAY

NO AGGREVATING AND RELIEVING FACTORS NO H/O FEVER

NO H/O CONSTIPATION PREVIOUSLY 2DAYS BACK NO H/O BURNING MICTURATION

NO H/O SIMILAR COMPLAINTS IN THE PAST

 

PAST HISTORY

K/C/O TYPE 2 DM, HTN

N/K/C/O ASTHMA, CAD, CVA, THYROID NO PAST SURGICAL HISTORY

ON EXAMINATION

PATIENT IS CONSCIOUS, COHERENT, CO OPERATIVE

NO PALLOR, ICTERUS, CLUBBING, CYANOSIS, LYMPHADENOPATHY, EDEMA TEMP- 96.3 F

PR- 68BPM

BP- 110/70MMHG GRBS- 146MG/DL RR- 16CPM

CVS- S1,S2 + RS- DYSPNEA+ SOB+

P/A: SOFT, NON TENDER

P/R- NO ANAL TAGS, ANAL TISSUE NOTED IN 6 O CLOCK POSITION AND NO FISTULAS ANAL TONE DECREASED

RECTUM LARGE

GLOVE STUNTED WITH STOOL CNS: NAD

COURSE IN THE HOSPITAL :

80 YRS MALE WAS ADMITTED WITH ABOVE MENTIONED COMPLAINTS. NECESSARY EXAMINATIONS AND INVESTIGATIONS WERW DONE AND DIAGNOSED AS HEART FAILURE WITH PRESERVED EJECTION FRACTION (EF 64%) ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE WITH POST RENAL AKI WITH PARTIAL PHIMOSIS RIGHT HYDROURETERONEPHROSIS , PROSTATOMEGALY WITH TRUE HYPONATREMIA WITH HYPERTENSION AND TYPE 2 DIABETES. THE PATIENT WAS CONSERVATIVELY MANAGED.

UROLOGY REFERRAL WAS DONE ON 18/8/23 :

- TAB TAMSULOSIN-D PO/HS X3 WEEKS

- SYP ALKASTONE B6 15ML 1/2 GLASS OF WATER PO/BD

- TAB PAN 40MG PO/OD BBF

- INJ ZOFER 4MG IV/SOS

- CAP BIO D3 PO/OD

 

- TAB NODOSIS PO/BD

- TAB NITROFURANTOIN 100MG PO/BD SURGERY REFERAL WAS DONE ON 22/8/23 :

- CST

- REVIEW USG ABDOMEN AND PELVIS I/V/O ABDOMINAL DISTENSION

- X RAY ERECT ABDOMEN

- CHEST X RAY (ERECT)

- REPEAT CBP , RFT , LFT

- DULCOLAX SUPPOSITORY PR/STAT (2)

- ABDOMINAL GIRTH MONITORING 4TH HRLY

- REVIEW WITH REPORTS

SURGERY REFERRAL WAS DONE ON 24/8/23 :

- CONTINUE SAME TREATMENT

- RYLES TUBE 16F WITH 2ND HRLY

- SYP CREMAFFIN 30ML PO/BD

- TAB DULCOLEX PO/OD/HS

- PLAN FOR CECT

- AMBULATE THE PATIENT

- REVIEW SOS

Investigation

FBS- 107

HBA1C- 6.7

PLBS- 197 ALBUMIN + SUGARS++

BILE SALTS /PIGMENTS- NIL NA+- 108

K+ 9.73

HB- 12MG/DL

TLC- 11100 CELLS

NEUTROPHILS- 85

LEUCOCYTES- 10

RBC- 4MILLIONS/CUMM RFT

 

UREA- 58

CREATININE- 2.2

URIC ACID- 5.3 NA+-126 CHLORINE- 93

2D ECHO DONE ON 19/8/23 :

- MODERATE TO SEVERE MR+; MILD AR+/TR+WITH PAH(ECCENTRIC MR+)

- NO RWMA. NO ASLMS, SCLEROTI AV

- GOOD LV SYSTLIC FUNCTIONS

NO DIASTOLIC DYSFUNCTION +; NO PE USG DONE ON 18/8/23 :

- RIGHT RENAL CALCULUS

- RIGHT HYDROURETERONEPHROSIS

- LEFT COMPLEX RENAL CORTICAL CYSTS

- GRADE I RAPID CHANGES IN B/L KIDNEYS REVIEW USG DONE ON 22/8/23 :

- VISUALIZED BOWEL LOOPS APPEAR COLLAPSED AND SHOW NORMAL PERISTALSIS

- NO ASCITES 21/8/23 :

SODIUM: 130 MEQ/L

POTASSIUM: 4.6 MEQ/L

CHLORIDE: 98 MEQ/L CALCIUM : 1.21 MMOL/L HEMOGRAM: 21/8/23 HB 9.8 GM/DL

TLC: 14400 CELLS CUMM PCV: 26.7 VOL %

RBC COUNT: 3.30 CELLS PLT: 2.47 LAKHS/CUMM RFT : 22/8/23 SODIUM:#133 MEQ/L POTASSIUM:5.0 MEQ/L CHLORIDE: 91 MEQ/L. BLOOD UREA: 54 MG/DL

 

SERUM CREATININE: 2.7 MG/DL URIC ACID : 5.2 MG/DL

24/8/23 : LFT :

TB: 0.82 MG/DL

DB: 0.18 MG/DL

SGOT: 23 IUL

SGPT: 20 IUL

ALP: 212 IUL

TP: 5.0 GM/DL

ALBUMIN: 3.1 GM/DL

A/G RATIO: 1.70 RFT : 24/8/23

SODIUM:#134 MEQ/L POTASSIUM:4.9 MEQ/L CHLORIDE: 97 MEQ/L. BLOOD UREA: 66 MG/DL

SERUM CREATININE: 3.0 MG/DL URIC ACID : 5.4 MG/DL HEMOGRAM: 24/8/23

HB 9.2 GM/DL

TLC: 27000 CELLS CUMM PCV: 26.8 VOL %

RBC COUNT: 3.17 CELLS PLT: 2.09 LAKHS/CUMM

REVIEW USG DONE ON 24/8/23 :

- VISUALISED BOWEL LOOPS APPEAR COLLAPSED WITH NORMAL PERISTALSIS

- NO ASCITES NOTED

Treatment Given(Enter only Generic Name)

IV FLUIDS NS @75ML/HR INJ. PAN 40MG IV/OD INJ. ZOFER 4MG IV/SOS INJ. HAI S/C TID

TAB. AMLODIPINE 10MG PO/OD

TAB METPROLOL SUCCINATE XL 25MG PO/OD

 

TAB ECOSPRIN AV 75/10 PO/HS

TAB METCLOPERAMIDE 10MG PO/HS INJ LASIX 40MG IV/BD

INJ MONOCEF 1GM IV/OD TAB. TAMSULOSIN-D PO/HS

TAB NITROFURANTOIN 100MG PO/BD

TAB SODIUM BICARBONATE 500MG PO/BD INJ NEOMOL 1GM IV/SOS

TAB PCM 650MG PO/TID CAP BIO D3 PO/OD

SYP ALKASTONE BC 15ML IN 1 GLASS OF WATER PO/BD SYP CREMAFFIN PLUS PO/BD

SYP DISODIUM HYDROGEN CITRATE PO/BD

NEBULIZATION WITH IPRAVENT 6TH HRLY , MOCOMIST 8TH HRLY , BUDECORT 12TH HRLY INJ VIT B12 IM/OD

GRBS PROFILE STRICT I/O CHARTING

MONITOR VITALS AND INFORM SOS

Advice at Discharge

PATIENT AND PATIENT'S ATTENDER HAVE BEEN EXPLAINED ABOUT PATIENT'S CONDITION AND ITS COMPLICATIONS AND NEED FOR FURTHER STAY IN HOSPITAL FOR FURTHER EVALUATION AND MANAGEMENT BUR THEY WANT TO LEAVE AGAINST MEDICAL ADVICE DUE TO PERSONAL REASONS (TREATMENT AT OTHER HOSPITAL).

DOCTORS , HOSPITAL STAFF AND MANAGEMENT ARE NOT RESPONSIBLE FOR ANY UNTOWARD COMPLICATIONS OF PATIENTS CONDITION.

First Encounter: 04/29/2024

• Outcome: mortality

Case 3

https://himajav.blogspot.com/2024/05/45f-htn-dm-hypothyroidism.html

Case 13

Cheif complaints 

A 45 year old female came to GM opd with chief complaints of Neckpain since 10 days and low grade fever since 10 days 

Patient was resident of guntur where she lives with her parents and her 3 siblings,she is a 3rd child,Did not go to school and entered handloom work at 10years of age.

She was married at age of 15years and and by the age of 17 she had first child and after 3 years of 1st child birth she got concieved had spontaneous abortion at 6months of gestational age due to work pressure and increased stress.3 years after the second pregnancy she had 3rd child and at 3 months of age the baby died due to fever.she felt depressed at worried about that event.After 3 years from that event she gave birth to 4th child with no health issues.

Since then she is doing fine with her life.

4 years ago she had h/o generalised weakness for which she went to local hospital and diagnosed of having hypertension and started on Tab.Losartan(50mg)+Tab.Hydrochlorthiazide(12.5 mg) and after starting that medication she felt better till 2 months

She is c/o neck pain since 10 days 

2 months back then she developed neck pain insidious in onset gradually progressive and aggravated since past 10 days. 

Restriction of movements+.

Neck Pain aggravates on flexion and extension of neck.

No h/o trauma. 

Low grade fever not associated with chills and rigors since 10 days,Intermittent in nature.

No h/o sob,cough,sore throat,Abdominal pain,vomitings,loose stools, Tingling of b/l upper limbs+.

Past History :

K/c/o htn since 4 years and on medication T. losertan 50 mg+Hydrochlorothiazide 12.5 mg po/od 

N/k/c/o DM, thyroid,CVA,epilepsy, Asthma,CAD

Personal History :

Appetite -Normal

Diet -Mixed

Sleep -Adequate 

Bowel and Bladder -Normal and Regular

Addictions -None

Daily Routine:

Patient is a Weaver by occupation. She works at her own house.

She wakes up by 6 am in the morning. She has her breakfast around 8 am. Then she starts her work by 9am. She works till 1pm. Then she has her Lunch by 2pm and sleeps for an hour. She continues her work till 6pm. She then has her dinner by around 8pm and goes to sleep by 10 pm.

The Daily Routine of the patient is disturbed due to severe neck pain since 10 days.

On General examination 

Patient is concious coherent cooperative 

Well oriented to time place person 

Moderately build and nourished

No Pallor ,Icterus ,cyanosis ,clubbing , koilonychia ,lymphadenopathy

Bilateral Pedal Edema +

Vitals 

Temperature – Afebrile ( 98.6 F )

Pulse rate – 80 bpm , regular 

Respiratory rate – 16 cpm

BP – 140/90 mm Hg 

SPO2 – 98% on room air  

GRBS – 256 mg/dl

Systemic Examination:

CVS- S1 S2 heard

RS- BLAE +

P/A- Soft,NT BS+

CNS:

HMF - Intact 

Speech – Normal 

Kernigs sign - Negative 

Brudzunski sign - Negative

Motor and sensory system – Normal 

Reflexes – Normal 

Cranial Nerves – Intact 

Gait – Normal

Cerebellum – Normal  

GCS Score – 15/15

Discharge summary 

Diagnosis

NECK PAIN- CERVICA RADICUOPATHY WITH PARASPINAL SPASM K/C/O HTN SINCE 4 YEARS WITH PERIPHERAL VERTIGO SECONDARY TO VERTEBRO BASILAR INSUFFICIENCY WITH DENOVO THYROID DISEASE (HYPOTHYROIDISM) WITH LEFT CERVICAL LYMPHADENOPATHY WITH DENOVO DM 2 WITH MIGRAINE

Case History and Clinical Findings

C/O NECK PAIN SINCE 10 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTS AGO THEN SHE DEVELOPED NECK PAIN OF INSIDIOUS ONSET GRADUALLY PROGRESSIVE AND AGGRAVATED SINCE PAST 10 DAYS. RESTRICTIPON OF MOVEMENTS PRESENT, PAIN AGGRAVATES ON FLEXION AND EXTENSION OF NECK.

LOW GRADE FEVER IS PRESENT NOT ASSOCIATED WITH CHILLS AND RIGORS SINCE 10 DAYS.

NO H/O COUGH, SOB, COLD, SORE THROAT, ABDOMINAL PAIN, VOMITINGS, LOOSE STOOLS, TINGLING OF BILATERAL UPPER LIMB.

NO H/O TRAUMA PAST HISTORY:

K/C/O HTN SINCE 4 YEARS AND ON T.LOSARTAN 50MG + HYDROCHLOROTHIAZIDE 12.5 MG N/K/C/O DMII,CVA,CAD,TB,EPILEPSY.

GENERAL EXAMINATION:

 

PATIENT IS CONSCIOUS, COHERENT,COOPERATIVE. MODERATELY BUILT AND NOURISHED

NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS,LYMPHEDENOPATHY,EDEMA VITALS:

TEMP: 98.6F PR: 78BPM

BP: 130/90MMHG RR: 18CPM

CVS: S1S2 HEARD RS: BAE+

P/A: SOFT, NONTENDER CNS EXAMINATION -NFND

PUPILS: NORAML IN SIZE, REACTIVE TO LIGHT TONE RT LT

UL NORMAL NORMAL LL NORMAL NORMAL POWER RT LT

UL 5/5 5/5 LL 5/5 5/5

REFLEXES RT LT BICEPS 2+ 2+

TRICEPS 2+ 2+

SUPINATOR 1+ 1+

KNEE 2+ 2+ ANKLE -- --

PLANTAR FLEXION FLEXION

NECK EXAMINATION:

NECK MOVEMENTS- RESTRICTED NECK STIFFNESS- ABSENT KERNIGS SIGN- NEGATIVE BRUDZINSKI SIGN- NEGATIVE RHOMBERG SIGN- NEGATIVE

FINGER FINGER INCOORDINATION- ANSENT

 

FINGER NOSE COORDINATION- ABSENT SPINE TENDERNESS- ABSENT NYSTAGMUS- ABSENT

EOM MOVEMENTS- NEGATIVE DIPLOPIA- ABSENT

NO RAISED ICT FEATURES

CERVICAL LYMPH NODES - PALPABLE ON LT OCCIPITAL ANGLE NO PALPABLE AXILLARY LYMPH NODES

THYROID SWELLING - PRESENT

GENERAL SURGERY REFFERAL WAS DONE ON 24/8/23 ADVICE :

NO ACTIVE SURGICAL INTERVENTION NEEDED

1. CONTINUE TREATMENT FOR HYPOTHYROIDISM

2. REVIEW AFTER 3 MONTHS IN GS OPD FOR REVIEW ORTHOPAEDICS REFFERAL WAS DONE ON 24/8/23 ADVICE:

DIAGNOSIS:CERVICAL DISC DEGENERATIVE DISEASE WITH MUSCLE SPASM OF NECK MUSCLES

TREATMENT:

TAB.HIFENAC MR BD 1 WEEK TAB. PAN 40MG OD 1 WEEK IFT/TENS APPLICATION

TAB. TRIGABATIN 100MG X 3 WEEKS

ENT REFFERAL DONE ON 24/8/23 I/V/O VERTIGO ADVICE

1.T.VERTIN 8 MG BD TO BE CONTINUED ENDOCRINOLOGY REFFERAL DONE ON 25/8/23 ADVICE:

1. DIABETIC DIET

2. T.THYRONOEM 75MCG

3. T.METFORMIN 500MG PO/BD

Investigation

22/8/23--23/8/23-- 26/8/23

 

TLC

5,300/4.300/ 10,000

HEMOGLOBIN 10.3/11.5/ 12.1 HEMATOCRIT

29.9/34.1/ 36.9

PLATLET 2.05/2.22/ 2.92/ IMPRESSION NCNC ANAEMIA/ NCNC NC NC ANAEMIA / BLOOD PICTURE

RFT

B.UREA 11/10/ 15

S.CREATININE 0.8/0.8/ 0.7 S.NA+ 137/138/ 139 S.K+

4.1/4.2/ 4.2

S.CL- 101/101/ 103 S.CA+2 1.20/1.18/ 1.17

LFT-22/8/23 T.BILURUBIN-0.77 D.BILURUBIN-0.20 AST-94

ALT-92

 

ALP-311 T.PROTEIN-7.2 ALBUMIN-4.1 CUE - 22/8/23 SUGAR- +++ ALBUMIN- NIL PUS CELLS: 3-4 RBC-NIL

CAST-NIL

SEROLOGY(HIV, HBSAG, HCV)-NEGATIVE BLOOD GROUP- B POSITIVE

ESR-40MM/1ST HOUR HB1AC-7.0

T3,T4,TSH-0.98, 8.70,29.51

USG NECK

IMPRESSION- DIFFUSE THYROIDITIS CERVICAL LYMPHADENOPATHY

TIRADS 3 LESION IN RIGHT LOBE OF THYROID

Treatment Given(Enter only Generic Name)

1. INJ.DICLOFENAC IM/SOS

2. INJ. ZOFER 4MG IV/SOS

3. T.PANTOP 40MG PO/OD

4. T.DOLO 650 MG PO/SOS

5. T. NICARDIA 10MG PO/SOS

6. T. LOSARTAN= T. HYDROCHLORTHIAZIDE 50MG/12.5 MG PO/OD

7. T.VERTIN 80MG PO/BD

8. T. THYRONORM 75MCG PO/OD

9. T. METFORMIN 500MG PO/BD

10. INJ.MYORIL (2ML) IM/BD

11. T.PREGABALIN 75MG PO/HS

12. T.CLONAZEPAM 0.25MG PO/HS

 

Advice at Discharge

1. INJ.DICLOFENAC IM/SOS

2. INJ. ZOFER 4MG IV/SOS

3. T.PANTOP 40MG PO/OD

4. T.DOLO 650 MG PO/SOS

5. T. NICARDIA 10MG PO/SOS

6. T. LOSARTAN= T. HYDROCHLORTHIAZIDE 50MG/12.5 MG PO/OD

7. T.VERTIN 80MG PO/BD

8. T. THYRONORM 75MCG PO/OD

9. T. METFORMIN 500MG PO/BD

10. INJ.MYORIL (2ML) IM/BD

11. T.PREGABALIN 75MG PO/HS

12. T.CLONAZEPAM 0.25MG PO/HS

First Encounter: 03/29/2024

• Outcome: Ongoing treatment for hypertension, diabetes mellitus, and hypothyroidism.

Case 4

https://himajav.blogspot.com/2023/10/65f-urosepsis-over-active-bladder.html

A 65 year old female, resident of west bengal and belonging to middle class according to modified kuppuswamy scale presented to the general medicine OPD with chief complaints of:

-continuous dribbling of urine since the past 4 years

- constipation since past 3 years.

- shortness of breath since 3 years.

 HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 26 years ago , when she developed:

* continuous dull aching pain in both the knee joints, which was exaggerated in the mornings and was bearable throughout the day, it was aggravated on walking and relieved on rest, associated with redness around the knees

- N/H/O trauma

- N/H/O fever with evening rise of temperature, cosmetic deformity(varicosity, skin discoloration)

- later as the disease progressed she underwent bilateral knee replacement surgery in the year 2015.

* continuous dribbling of urine since 4 years, which was insidious in onset with a few drops during the day and gradually progressed to continue throughout the day and wetting of bed during the night, urine is yellow in color with ammonical odour. Aggravated on consumption of coffee & drinking more than 1.5 lit of water.

* patient reports recurrent UTIs where in she complains of 

-burning micturition

-pain before and while micturition

-no history of hematuria, frothy urine

* patient also reports constipation since 3 years,

- she passes 1 bowel movement per 2-3 days , associated with pain 

- patient passes flatus

- not associated with blood, abdominal distention, weight loss 

* fever since 1 day, sudden onset, high grade, continuous, no aggravating and relieving factors, associated with bodyache, headache.

HISTORY OF PAST ILLNESS: 

- H/O rheumatoid arthritis since past 26yrs, is on regular medication. 

- H/O HTN since past 20yrs on regular medication.

- H/O SOB since past 3years due to seasonal changes (usually in cold weather) and in stressful situations, she uses specified medication (inh. budetrol 400, oxymethazoline hydrochloride nasal drops)

-K/C/O DM since 10 days 

- N/K/C/O TB, CVD, Asthma, Epilepsy, Thyroid disorders, blood transfusions. 

SURGICAL HISTORY:

- history of bilateral knee replacement 8 years ago. 

- history of LSCS 27yrs ago

PERSONAL HISTORY: 

- Married  

- Mixed diet 

- Decreased appetite due to fullness of abdomen 

- Adequate sleep

- Decreased bowel movement lead to constipation since past 3 yrs

- micturition: urinary incontinence since past 4yrs

- No known allergies 

- no known addictions

DRUG HISTORY:

-Tab.METFORMIN 500mg 

- Tab. METHOTREXATE 10mg.

- Tab. FOLIC ACID 5mg.

- Tab. CLINIDIPINE, TELMISARTAN & CHLORTHIDONE.

- Tab. BISOPROLOL FUMARATE.

- Tab. NORTRIPTYLINE, MECOBALAMIN & PREGABALIN.

- Tab. MIRABEGRON Extended release. 

- Tab. RAVEPRAZOLE SODIUM 20mg & DOMPERIDONE 30mg.

- Syp. LIQUID PARAFFIN, MILK OF MAGNESIUM & SODIUM PICOSULFATE.

- Inh. BUDESONIDE.

FAMILY HISTORY:

- the patient’s mother and younger sibling are known cases of osteoarthritis 

GENERAL EXAMINATION: 

I have examined the patient after taking prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room.

First Encounter: 10/22/2023

• Outcome: Stabilized after urosepsis treatment and management of overactive bladder.

Morbidity 

Case 5

65 Y Old female came to casualty with C/O fever since 4 days,Shortness of breath since 2 days,pedal edema since 2 days.

Past and present history:-

This is a case of 65 year old female resident of nagarjuna sagar presented to casuality with above complaints.

Pt wa lols born and brought up in nagarjuna sagar and studied up to 10th standard.Was married at the age of 17years and had two female children at the age of 18 and 21 years.

Her husband was a lorry driver and 20 years back he met with RTA and expired.She was worried about her husband death and gradually it effected her daily routine.she started to consume more than required to deviate her mind from husband demise and started to gain weight.she was apparently asymptomatic till 10 years ago and developed neck pain and headache for which she went to hospital and diagnosed of having htn and started on antihyoertensives(tab.telma 40 and metxl trio) and till 3 years back she remained asymptomatic and then developed   generalised weakness,polyuria and polydysia for which she was diagnosed of having DM2 and started onOHA's which later converted to inj.mixtard as her sugars remain uncontrolled with OHAs.In 2020 she develeoped chest pain o acute onset and CABG was done i/v/o CAD and since january 2023 she is having sob and pause of breaths during sleep and diagnosed of having OSA and was on intermittent bipap at home 

Present illness:-4 days back she develeoped fever of highgrade intermittent relieved of medication and 2 days ago she developed pedal edem(b/l) and pain iver dorsum of rt foot for which hot compressions were applied and sob of grade 2 since 2 days not associated with cough,palpitations,chestpain ,profuse sweating 

Past illness in brief:-

K/c/o htn since10 yrs on tab.telma 40 and tab.met xl trio

K/c/o DM2 since 3 years and on injj.mixtard  sc. bd

K/c/o CAD s/p CABG in 2020

K/c/o OSA Since jan 2023

General examination

Pt is c/c/c

Pallor +

B/l pedal edema +

No icterus cyanosis clubbing lymphadenopathy

Ulceration over dorsum of rt foot+

Temp afebrile 

Bp 150/80 mm hg

Pr 86 bpm

Rr 18cpm

Systemic examination

Cvs : s1 s2 heard no murmurs

Cns:nfnd

Rs:Blae+Nvbs

P/A: soft non tender

Ht:-5.4/wt:- 120 kgs

pulmonology referral was done i/v/o cough and sob they adviced tab. Acebrophylline 100mg bd

Nebs ith ipravent 6th hrly budecort 8th hrly

Tab pcm 650 tid

O2 inhalation 1to 2lt/min to maintain spo2 above 95%

Surgery refrl was taken I/V/O RT LOWER LIMB CELLULITIS, BEDSORE,GANGRENE OF 5TH TOE

TREATMENT- TAB . CHYMEROL FORTE 10MG PO TID

MGSO4 +GLYCERINE DRESSING, AIR BED

DISARTICULATION OF RIGHT5 TH TOE WITH DEBRIDEMENT OF ULCER AND BEDSORE UNDER SA DONE ON 24/11/23

DVL REFERRAL I/V/O ITCHY SKIN LESIONS OVER GROIN AND INNER THIGHS

TREATMENT- CLOTRIMAZOLE 1% CREAM L/A BD X 1 WEEK

ABZORB DUSTING POWDER L/A BD X 2 WEEKS

COURSE IN THE HOSPITAL-

A 65 YR OLD FEMALE PRESENTED WITH C/O FEVER SINCE 4 DAYS, SHORTNESS OF BREATH SINCE 2 DAYS, PEDAL EDEMA SINCE 2 DAYS,

SOB GRADE III AND ON FURTHER INVESTIGATIONS DIAGNOSED WITH TYPE II DIABETES MELLITUS ,HYPERTENSION .K/C/O CAD S/P CABG IN 2020,

ACUTE KIDNEY INJURY ,GANGRENE OF 5TH TOE, ULCER OVER DORSUM OF FOOT & RT CALF,GRADE II BEDSORE OF B/L GLUTEAL REGION S/P DISARTICULATION OF 5TH RT TOE & DEBRIDEMENT OF ULCER & BEDSORE UNDER SA ,CANDIDIAL INTERTRIGO +FRICTIONAL DERMATITIS.

S/P 9 SESSIONS OF HEMODIALYSIS DONE , 4 BLOOD TRANSFUSIONS DONE

PATIENT IS MANAGED CONSERVATIVELY WITH ANTIBIOTICS AND PLANNED FOR DISCHARGE

DEATH SUMMARY

THIS IS A CASE OF 65 YR OLD FEMALE FROM NAGARJUA SAGAR , HOUSEWIFE BY OCCUPATION, WHO IS K/C/O OBSTRUCTIVE SLEEP APNEA W/ HEART FAILURE W/ PRESERVED EJECTION FRACTION W/ ANEMIA OF CHRONIC DISEASE , PULMONARY HYPERTENSION TYPE III , ULCER ON DORSUM OF RIGHT FOOT W/ GRADE I BED SORE W/ DIABETES MELLITUS TYPE II W/ HYPERTENSION W/CKD . S/P PTCA IN 2015 , S/P CABG IN 2020 W/ 9 SESSIONS OF HEMODIALYSIS  W/ S/P DEBRIDEMENT OF RIGHT FOOT W/ AMPUTATION OF 4TH AND 5TH TOES OF RIGHT FOOT . PREVIOUSLY ADMITTED UNDER US FOR SHORTNESS OD BREATH FOR 25 DAYS AND ULCER ON DORSUM OF RIGHT FOOT . PT WAS DISCHARGED FROM OUR HOSPITAL W/ HOME OXYGENATION SUPPORT AND WAS ON CONSERVATIVE MANAGEMENT W/ INTERMITTENT BiPAP SUPPORT . PT WAS ADMITTED IN DISTRICT HOSPITAL FOR OXYGEN SUPPORT. PT WAS MAINTAINING SP02 96% ON 2-3 LITRES OXYGEN SUPPORT . SHORTNESS OF BREATH AGGRAVATED SUDDENLY FOR 2 HRS AND OXYGEN REQUIREMENT INCREASED UPTO 6-8 LITRES AND PT CAME TO OUR CASUALITY FOR FURTHER MANAGEMENT.

AT THE TIME OF ADMISSION, BP - 120/80 MMHG , PR-100BPM , RR-20CPM , TEMP -101F , GRBS-208 MG/DL , SP02 - 80% ON RA , 97% ON 4 LIT O2 . ABG SHOWED - PH -7.364 , PC02 -48.1 , P02 -44.6 , HC03 -26.7 , HB-7.6 , TLC - 9600 , PLTS-4.5 LKHS, CREAT-1.7 , UREA -70 . PT WAS MAINTAINED ON INTERMITTENT CPAP AND BIPAP SUPPORT . FOLLOWING ADMISSION , BED SORE HAS PROGRESSED FROM GRADE II TO GRADE III. AFTER SENDING BLOOD AND URINE CULTURES , IV ANTIBIOTICS WERE STARTED AFTER 5 DAYS OF ADMISSION. PT HAS INTERMITTENT FEVER SPIKES THROUGHOUT THE DAY , IV ANTIBIOTICS WERE ESCALATED. 2D ECHO REVEALED PULMONARY ARTERY HYPERTENSION  FOR WHICH CONSERVATIVE MANAGEMENT WAS GIVEN . REGULAR DRESSINGS WERE DONE FOR ULCER ON DORSUM OF RIGHT FOOT AND STARTED MUCIPROCIN OINT FOR SCAB ON THE BEDSIDE . 2 PRBS TRANSFUSIONS WERE DONE FOR CORRECTION OF ANEMIA , 1 INJ ALBUMIN 20% IV STAT; CORRECTION WAS DONE I/V/O LOW SERUM ALBUMIN AND PROTEIN RICH DIET WAS ADVISED . AS COAGULATION PROFILE WAS DERANGED aPTT-55 S, PT-26 S, INR-1.9 , 4 FFP TRANSFUSIONS WERE DONE AND INJECTION VIT K WAS GIVEN.

PT WAS MAINTAINED ON INTERMITTENT CPAP SUPPORT SINCE ADMISSION. ON 19/12/23 , ABG SHOWED PH-7.2 , PCO2 -66.4 , P02 -80 , HCO3- -25.5 , S02 -95.5 . AS THE PT STARTED DEVELOPING TYPE II RESPIRATORY FAILURE . PT WAS KEPT ON CONTINUOUS CPAP SUPPORT THROUGHTOUT THE NIGHT EVEN AFTER WHICH CO2 RETENTION WAS PRESENT . PT WAS INTUBATED AND CONNECTED TO MECHANICAL VENTILATOR . ON THE NEXT DAY, PT WAS KEPT ON ACMV-VC MODE ON FiO2 60. 4 HRS AFTER INTUBATION THERE WAS A DROP IN 02 SATURATION . PULSE AND BP WERE NOT RECORDABLE CPR WAS INITIATED ACCORDING TO LATEST ACLS GUIDELINES AND WAS CONTINUED UPTO 30 MIN . INSPITE OF ABOVE RESUSCITATIVE EFFORTS PT COULD NOT BE REVIVED AND WAS DECLARED DEAD AT 12:10 PM AS THE ECG SHOWED FLATLINE.

IMMEDIATE CAUSE OF DEATH:- TYPE II RESPIRATORY FAILURE

ANTECEDENT CAUSE OF DEATH:- OBSTRUCTIVE SLEEP APNEA , HEART FAILURE WITH PRESERVED EJECTION FRACTION , ULCER ON DORSUM OF FOOT , GRADE II BED SORE (B/L GLUTEAL) , ANEMIA OF CHRONIC DISEASE , CKD, PAH, DM II , HTN. 

First Encounter: 08/18/2023

• Outcome: Expired due to sepsis complications.

Case 6

https://himajav.blogspot.com/2024/02/70f-hfpef-ckd-hypoalbuminemia.html

A 70-year-old woman from Gouravaram, born into a lower middle-class family, lacked formal education, and was married at 14 in a non-consanguineous union. Having a pleasant childhood with three siblings, she turned to farming for a livelihood, raising two sons and a daughter. Her father's early demise and mother's passing 12 years ago due to old age left an impact. Eight years ago, her husband, facing similar issues as she does now, passed away after dialysis. Knee pain and fatigue led her to cease daily tasks, cared for by her elder son. Recently, she developed shortness of breath, pedal edema, and reduced urine output, initially diagnosed with CKD, and is now experiencing a recurrence after conservative management

.PATIENT WAS BROUGHT TO CASUALTY WITH CIO SWELLING OF BOTH LOWER LIMBS SINCE 20 DAYS

CIO FACIAL PUFFINESS SINCE 20 DAYS

CIO SHORTNESS OF BREATH SINCE 4 DAYS

HOPI

PATIENT WAS APPARENTLY ASYMPTOMATIC 20 DAYS BACK THEN DEVELOPED SWELLING OF BOTH LOWER LIMBS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, PITTING TYPE C/O FACIAL PUFFINESS SINCE 20 DAYS

CIO SOB SINCE 4 DAYS INSIDIOUS IN ONSET GRADE 4NYHA GRADUALLY PROGRESSIVE

HIO ORTHOPNEA

HO CHEST PAIN FEVER, BURNING MICTURATION, ABDOMINAL DISTENSION NO H/O ABDOMINAL PAIN

NO H/O PALPITATIONS, DECREASED URINE OUTPUT PAST HISTORY:

KICIO HYPERTENTION SINCE 15 YRS ON TAB AMLODIPINE 5MG PO OD

DM II SINCE 10 YRS ON TAB GLlMI MI POOD

HIO TB 30 YRS BACK USED MEDICATION, COMPLETE COURSE NIKICIO ASTHMA, CVA, CAD, EPILEPSY PERSONALHISTORY:

DIET MIXED

SLEEP ADEQUATE

BOWEL AND BLADDER:STOOL NOT PASSED SINCE 3 DAYS, DECRESED URINE OUTPUT ADDICTIONS ALCOHOL SINCE 20 YRS STOPPED 3 MONTHS BACK APPETITE: DECREASED GENERAL EXAMINATION:

PATIENT IS CONSCIOUS COHERENT COOPERATIVE WELL ORIENTED TO TIME, PLACE AND PERSON

NO PALLOR, ICTERUS, CYANOSIS, CLUBING LYMPHADENOPATHY, EDEMA.

VITALS:

TEMPERATURE:98.6

BP:180/90 MM HG

PR: 64 BPM

RR.18 CPM

SYSTEMIC EXAMINATION

CVS.81,82 HEARD NO MURMURS.

RS.BAE + NO MURMURS

PER ABDOMEN SOFT,NON TENDER, NO ORGANOMEGALY CNS.NO FOCAL NEUROLOGICAL DEFICITS.

NEPHROLOGY REFERRAL DONE ON 21/ 1/24 LV/O INCREASED UREA AND CREATININE

ADVICE COLLAGEN PROFILE, URINE FOR BENCE ZONE PROTEIN, REVIEW WITH REPORTS,

DIAGNOSIS:

70 YR FEMALE/ 80 KGS

1. STAGE V CHRONIC KIDNEY DISEASE

NEPHROTIC SYNDROME SECONDARY Th ? DIABETIC NEPHROPATHY

PRENAL AMYLOIDOSIS

?MYELOMA KIDNEY|

HEART FAILURE WITH PRESERVED EJECTION FRACTION

HYPERTENSION/TYPE II DM 

OLD PULMONARY KOCHS[30YRS AGO]

OPHTALMOLOGY REFERRAL DONE ON 22/1/24 IMO RETINOPATHY CHANGES DUE TO DIABETESIMPRESSIONINO EVIDENCE OF DIABETIC RETINOPATHYADVICE: STRICT

DIABETIC DIET, FUNDUS EXAMINATION FOR EVERY 6 MONTHS

COURSE IN THE HOSPITAL 

PATIENT WAS BROUGHT WITH ABOVE MENTIONED COMPLAINTS ANDWAS DIAGNOSED AS DIABETIC NEPHROPATHY SYMPTOMATIC TREATMENT WAS GIVEN.THEN HYPONATRAEMIA OCCURED FOR WHICH 39 NACLINFUSION WAS STARED FOR WHICH NO IMPROVEMENT OBSERVED. NEPHROLOGY REFERRAL WAS DONE ADVISED INJ ALBUMIN 3

TRANSFUSIONS 2 ALBUMIN TRANSFUSIONS WERE DONE BUT NO IMPROVEMENT WAS THERE SO ADVISED FOR HEMO DIALYSIS BUT PATIENT ATTENDERS ARE NOT WILLING FOR HEMODIALYSIS AND WANT TO LEAVE AGAINST MEDICALADVICE

First Encounter: 01/17/2024

• Outcome: lost to followup

Case 7

https://himajav.blogspot.com/2024/04/65m-bph-rhf-lvh.html

A 65-year-old man, raised in Palivada from a consanguineous marriage, had a typical childhood. He completed his education up to the 10th standard. During his schooling, he and his friends once got into trouble, leading to them failing their exams. At 18, he chose farming over a potential career as a police officer. He now owns 4 acres of land and is married to his sister-in-law, with whom he has three children. His eldest son, an engineering graduate, is currently unemployed in Hyderabad. His second son works as a mechanic in Nalgonda due to a congenital heart defect, while his daughter pursued B.E.D. Over the last three years, he has experienced knee pain, forcing him to sell his cattle. His daily routine involves waking up at 6 am, working on the farm, and returning home at noon for lunch and a nap. In the evening, he socializes with fellow villagers before retiring for the night. Recently, he developed symptoms such as pedal edema, decreased urine output, and shortness of breath, despite no history of hypertension, diabetes, or other major health issues. His personal habits include moderate alcohol consumption twice a week, with no smoking history.

TEMP-98.6F

PR- 86 bpm

RR- 18cpm

BP- 110/80mmhg

CVS-S1S2 NO MURMUR

R/S- BAE NVBS

P/A- SOFT NT

CNS- NFND

Discharge summary

Diagnosis

HEART FAILURE WITH PRESERVED EJECTION FRACTION HYPONATREMIA [HYPERVOLEMIC HYPONATREMIA] BENINGN PROSTATIC HYPERPLASIA

Case History and Clinical Findings

PATIENT CAME WITH C/O BILATERAL PEDAL EDEMA SINCE 15 DAYS DECREASED URINE OUTPUT SINCE 15DAYS

SOB SINCE 10 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS AGO THEN HE DEVELOPED BILATERAL PEDALEDEMA PITTING TYPE EXTENDING UPTO KNEE JOINT H/O DECREASED URINE OUTPUT SINCE 15 DAYS SOB SINCE 10 DAYS INSIDIOUS ONSET AND GRADUALLY PROGRESSIVE FROM GRADE 1 TO GRADE 2 [ MMRC] ORTHOPNEA POSITIVE NO PND

NO H/O WHEEZE, DIURNAL AND SEASONAL VARIATION, FEVER, COUGH, VOMITING, LOOSE STOOLS, PAIN ABDOMEN, GIDDINESS

NO SIGNIFICANT PAST HISTORY PATIENT IS C/C/C

GC FAIR

BILATERAL PEDAL EDEMA PRESENT , PITTING TYPE EXTENDING UPTO KNEE JOINT NO SIGNS OF PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY

TEMP : 96.8F PR : 88 BPM RR : 20 CPM

 

BP : 130/80 MMHG SPO2 : 98%

GRBS : 100 MG % CVS- S1S2 HEARD

RS- BA POSITIVE NVBS HEARD CNS- NFD

P/A : SOFT AND NON TENDER

Investigation

NameValueRangeNameValueRangeBLOOD UREA22-04-2024 11:55:AM20 mg/dl50-17 mg/dlSERUM CREATININE22-04-2024 11:55:AM0.9 mg/dl1.3-0.8 mg/dlSERUM ELECTROLYTES (Na, K, C l) 22-04-2024 11:55:AM SODIUM124 mmol/L145-136 mmol/LPOTASSIUM3.2 mmol/L5.1-

3.5 mmol/LCHLORIDE98 mmol/L98-107 mmol/LCOMPLETE URINE EXAMINATION (CUE) 22-04- 2024 11:55:AM COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN+SUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS3-6EPITHELIAL CELLS2-4RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilLIVER FUNCTION TEST (LFT) 22-04-2024 11:56:AM Total Bilurubin1.89 mg/dl1-0 mg/dlDirect Bilurubin0.50 mg/dl0.2-

0.0 mg/dlSGOT(AST)21 IU/L35-0 IU/LSGPT(ALT)28 IU/L45-0 IU/LALKALINE PHOSPHATASE140 IU/L119-56 IU/LTOTAL PROTEINS6.6 gm/dl8.3-6.4 gm/dlALBUMIN4.1 gm/dl4.6-3.2 gm/dlA/G RATIO1.68HBsAg-RAPID22-04-2024 05:18:PMNegative Anti HCV Antibodies - RAPID22-04-2024 05:18:PMNon Reactive ABG 22-04-2024 07:04:PM PH7.39PCO234.5PO280.3HCO320.7St.HCO322.0BEB-2.9BEecf-3.4TCO238.9O2 Sat96.3O2 Count23.4POST LUNCH BLOOD SUGAR22-04-2024 10:44:PM100 mg/dl140-0 mg/dlSERUM CREATININE22-04-2024 10:44:PM0.8 mg/dl1.3-0.8 mg/dlSERUM ELECTROLYTES (Na, K, C l) 22- 04-2024 10:44:PM SODIUM140 mmol/L145-136 mmol/LPOTASSIUM3.5 mmol/L5.1-3.5 mmol/LCHLORIDE106 mmol/L98-107 mmol/LSERUM ELECTROLYTES (Na, K, C l) 23-04-2024 04:25:PM SODIUM139 mmol/L145-136 mmol/LPOTASSIUM3.1 mmol/L5.1-3.5 mmol/LCHLORIDE101 mmol/L98-107 mmol/LLIVER FUNCTION TEST (LFT) 23-04-2024 11:30:PM Total Bilurubin2.00 mg/dl

1-0 mg/dl

Direct Bilurubin0.40 mg/dl0.2-0.0 mg/dlSGOT(AST)20 IU/L35-0 IU/LSGPT(ALT)24 IU/L45-0 IU/LALKALINE PHOSPHATASE133 IU/L119-56 IU/LTOTAL PROTEINS6.1 gm/dl8.3-6.4

gm/dlALBUMIN3.8 gm/dl4.6-3.2 gm/dlA/G RATIO1.69UREA19 mg/dl50-17 mg/dlCREATININE0.8 mg/dl1.3-0.8 mg/dlURIC ACID4.5 mmol/L7.2-3.5 mmol/LCALCIUM10.0 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.9 mg/dl4.5-2.5 mg/dlSODIUM139 mmol/L145-136 mmol/LPOTASSIUM3.5 mmol/L.5.1-3.5 mmol/L.CHLORIDE102 mmol/L98-107 mm

HEMOGRAM

 

HB : 14.7 G/ DL

TOTAL COUNT : 6500 CELLS/ CUMM PCV : 37.7

RBC COUNT : 4.70 MILLIONS/CUMM PLATELET COUNT : 2.60 LAKH/CUMM

IMPRESSION NORMOCYTIC NORMOCHROMIC BLOOD PICTURE USG ABDOMEN DONE ON 22/04/2024

IMPRESSION: MILD SPLENOMEGALY , GRADE I FATTY LIVER , GRADE III PROSTATOMEGALY 2 D ECHO WAS DONE ON 22/04/2024

IMPRESSION : TRIVIAL AR , TRIVIAL MR ,NO TR NO RWMA , NO AS/MS SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION , NO PAH/PE

Treatment Given(Enter only Generic Name)

PATIENT WAS DIAGNOSED WITH

HEART FAILURE WITH PRESERVED EJECTION FRACTION HYPONATREMIA [HYPERVOLEMIC HYPONATREMIA] BENINGN PROSTATIC HYPERPLASIA AND TREATED AS

ON 25/04/2024 UROLOGY REFFERAL WAS TAKEN I/V/O GRADE III PROSTATOMEGALY AND ADVISED TAB : RAPILIF-D PO/HS FOR 3 MONTHS , SYP CREMAFFIN 15 ML HS X 2 WEEKS TAB : LASIK 20 MG PO/BD

INJ : PAN 40 MG IV/ OD TAB : ECOSPRIN AV PO/OD TAB : URIMAX-D PO/OD

TAB : MRT-XL 12.5 MG PO/OD TAB : THIAMINE 200 MG PO/OD

Advice at Discharge

TAB LASIX 20 MG PO/BD X 10 DAYS TAB ECOSPRIN AV PO/OD X 10 DAYS TAB RAPILIF D PO/OD X 3 MONTHS TAB MET XL 12.5MG PO/OD X 10 DAYS

TAB THIAMINE 200 MG PO/OD X 10 DAYS TAB PAN 40 PO/OD X 10 DAYS

SYP CREMAFFIN 15 ML PO/HS X 10 DAYS

First Encounter: 04/26/2024

Case 8

https://himajav.blogspot.com/2024/04/70m-htn-dm-cad.html

A 70-year-old man, born and raised in Gundrapally within a low socioeconomic environment, recalls a pleasant childhood despite lacking formal education. Among four siblings, three have passed away. At the age of 12, he assumed responsibility for tending to approximately 50 cattle, including sheep, goats, buffaloes, and cows. By 25, he transitioned into farming, cultivating 50 acres of land under the supervision of a wealthy landowner, cultivating a variety of crops such as oranges, wheat, and various grains. His marriage at 25 was arranged by his brother and father to a non-relative. He adopted smoking at 25 as a means to remain alert and energetic, while alcohol consumption became a customary practice in their culture, used for socializing or to induce sleep when exhausted or during village disputes. He has three sons engaged in construction work and a daughter married to a farmer who passed away due to alcohol-related issues. His daughter has three children, while each of his sons has started their own families. 

Twenty years ago, he suffered a slip and fall resulting in a fractured tibia, requiring a three-month period of bed rest and herbal treatment, thereafter relying on a walking stick and discontinuing physical labor. Subsequently, he has remained at home, gradually accumulating visceral fat. A decade ago, he experienced sudden and severe chest pain, seeking treatment at Yashoda Hospital in Hyderabad, where he received immediate relief from medication followed by PTCA and stent placement. He has since remained symptom-free. Three years ago, he was diagnosed with hypertension during a hospital visit for fever, initially treated with a 2-rupee tablet, later switched to a 5-rupee tablet, and currently managed with Tab Telma 40mg. Two years ago, he sought medical attention for dizziness and was diagnosed with diabetes, subsequently managed with oral hypoglycemic agents.

Chief complains

Complaining of shortness of breath persisting for one year and swelling in both lower limbs for the past month. 

History of presenting illness

Patient was reportedly asymptomatic a year ago but subsequently developed shortness of breath, starting gradually at Grade I NYHA and progressing to Grade III NYHA, without associated chest pain or sweating. Additionally, the patient reports experiencing abdominal distension, poor urinary stream, nocturia, and hesitancy, but no urgency. The patient also has a cough with scanty, whitish sputum that is non-blood stained and non-foul smelling. Furthermore, there is pedal edema of the pitting type extending up to the knees, along with facial puffiness.

Daily routine

Twenty years ago, his daily routine involved waking up multiple times during the night— at 12 am, 3 am, and 5 am— to switch on the motor for watering the fields. Upon waking, he would clean the cattle area before heading out to the fields for farming activities such as ploughing and harvesting, depending on the season. During breaks, he would rest under a tree to rejuvenate himself. Lunch, typically consisting of rice and curry, was consumed around 12 pm, followed by more work in the fields before returning home. Evenings were dedicated to bhajans and storytelling sessions, often centered around the Bhagavadgita. Dinner would be had at home before retiring for bed around 10 pm. He explained that in those days, time was gauged by observing the stars; they could identify specific stars and use their position to estimate the time, a practice they continue to follow.

During our conversation about his past routines, I discovered that his village had limited knowledge of allopathic medicine and relied heavily on herbal remedies. Leaves of plants such as paithala Bhairavi were used for urinary issues, while sugandha and Satya were employed for nerve-related ailments. He expressed regret over his current inability to venture out due to his mobility issues, as he used to visit the Sreesailam forest to gather leaves for his health.

In contrast, his present daily routine involves waking up around 5 am but spends most of the day idle at home, smoking beedis and socializing with friends. He returns home for lunch, takes a nap, and repeats the same pattern in the evening.

Vitals

Temp-98.6F

PR-80bpm

RR-22cpm

BP-110/80mmhg

CVS:S1S2 Heard, No murmurs

RS: BAE Present, NVBS heard

PA: Soft NT

CNS: NFND

Diagnosis

HEART FAILURE WITH PRESERVED EJECTION FRACTION (60%) CHRONIC KIDNEY DISEASE

K/C/O CAD SINCE 6 YEARS K/C/O HTN SINCE 6 YEARS K/C/O DM II SINCE 6 YEARS

Case History and Clinical Findings

C/O SOB SINCE 1 YEAR

C/O SWELLING OF BILATERAL LOWER LIMBS SINCE 1 MONTH HOPI:

PT WAS APPARENTLY ASYMPTOMATIC 1 YEAR BACK, THEN HE DEVELOPED SOB OF INSIDIOUS ONSET INITIALLY GRADE I NYHA, GRADUALLY PROGRESSIVE TO GRADE III NYHA, NOT A/W CHEST PAIN, SWEATING.

H/O ABDOMINAL DISTENSION

H/O POOR STREAM OF URINE, NOCTURIA H/O HECITENCY

NO H/O URGENCY

H/O COUGH WITH SPUTUM, SCANTY, WHITISH IN COLOUR, NOT BLOOD STAINED, NON FOUL SMELLING

H/O PEDAL EDEMA, PITTING TYPE, EXTENDING UPTO KNEES H/O FACIAL PUFFINESS

PAST HISTORY:

K/C/O HTN SINCE 6 YEARS ON TAB AMLOKIND AT 5/50 K/C/O CAD SINCE 6 YEARS ON TAB CLOPITAB

K/C/O DM SINCE 5 YEARS ON TAB METFORMIN 500MG N/K/C/O CVA, SEIZURES, TB, THYROID DISORDERS. ON EXAMINATION:

PT IS CONCIOUS, COHERENT AND COOPERATIVE PALLOR- PRESENT

NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA. TEMP- AFEBRILE

BP- 110/80MMHG PR- 80BPM

RR- 22CPM SPO2- 98%

CVS- S1 S2 HEARD, NO MURMURS

RS- BAE +, NVBS +, B/L DIFFUSE RHOCHI FINE CREPTS +, RT SAA, MA P/A- SOFT, NON TENDER

COURSE IN THE HOSPITAL:

PT WAS ADMITTED IN THE VIEW OF B/L PEDAL EDEMA SINCE 1 MONTH AND SON SINCE 1 YEAR AND STARTED TREATMENT WITH NEBULIZATIONS, INSULIN AND WITH LOOP DIURETICS, CCB'S, NODOSIS, SHELCAL CT, OROFER XT (AS HIS HB WAS 7.8) , VITAMIN C AND MAINTAINED BLOOD SUGAR VALUES IN NORMAL RANGE. RFT ALSO SHOWED GRADUAL IMPROVED FUNCTIONING OF THE KIDNEY. I/O CHARTING WAS MAINTAINED ALONG WITH IV FLUIDS. HB WAS GRADUALLY INCREASED TO 9MG/DL. PT WAS WELL MAINTAINED AND DISCHARGED IN HAEMODYNAMICALLY STABLE CONDITION.

First Encounter: 08/12/2023

• Outcome: morbidity

Case 9

https://himajav.blogspot.com/2024/05/66f-hypoglycemic-seizures.html

A 66-year-old woman, hailing from Narketpally, had a traditional upbringing alongside her two younger brothers and a sister. She lost her father to cancer and mother expired one year later.Despite her education halting at the 8th standard due to marriage at age 10, she embraced homemaking, facing the heartache of losing her first child and later nurturing two sons, one through 12th grade and the other through primary education. Sadly, her husband passed away 25 years ago, followed by her elder son leaving home two years later. Entrusted by her brother, she managed an old age home housing 40 residents, which became her livelihood, earning around 2 lakhs monthly. Using her income, she bought gold for herself and her grandson's wedding. Health issues emerged 25 years ago with hypertension, followed by a hysterectomy due to uterine infection 20 years ago, leading to post-operative complications and weight gain. Diabetes was diagnosed 15 years ago, and recently, hypothyroidism was discovered, necessitating thyronorm 12.5mcg. On occasion, she skips meals when unwell, as on April 29th when feverish, leading to hypoglycemic seizures from missed  dinner after taking insulin.

Her daily routine involves rising at 5 am to prepare tea for 60 individuals, followed by overseeing meals and tasks at the old age home, punctuated by a one-hour nap post-lunch. Chitchatting with the other elderly ladies advising how to deal with matters. She is like a gang leader to the old age home ladies.

Discharge summary 

Diagnosis

HYPOGLYCEMIC SEIZURES (RESOLVED) HYPOGLYCEMIA SECONDARY TO INSULIN

K/C/O TYPE 2 DIABETES MELLITUS SINCE 20 YEARS K/C/O HYPERTENSION SINCE 20 YEARS

K/C/O HYPOTHYROIDISM SINCE 6 MONTHS CHRONIC KIDNEY DISEASE

Case History and Clinical Findings

CHIEF COMPLAINTS:

INVOLUNTARY MOVEMENTS OF UPPER LIMBS AND UPPER LIMBS SINCE 1 HOUR FROTHING FROM MOUTH SINCE 10 MIN

HOPI:

PATIENT WAS APPARENTLY ALRIGHT 1 HOUR BACK THEN HE DEVELOPED INVOLUNTARY MOVEMENTS OF HANDS, UPPER LIMB AND LOWER LIMB LASTING FOR 30 MIN ANG GOT SLURRING OF SPEECH, BLABBERING FOLLOWED BY FROTHING. H/O INTAKE OF 10 UNITS OF HAI AND 10IU OF NPH BEFORE SEIZURE EPISODES. NO H/O VOMITING, DIARRHEA

NO H/O HEADACHE, BLURRING OF VISION NO H/O TRAUMA

NO H/O BOWEL AND BLADDER INVOLUNTARY MOVEMENTS K/C/O HYPOTHYROIDISM ON THYRONORM 12.5 MG

K/C/O DM 2 SINCE 20 YEARS ON HAI 10UNITS AND NPH 10UNITS

 

K/C/O HYPERTENSION SINCE 18 YEARS ON TELMISARTAN

PERSONAL HISTORY:

MARRIED

OCCUPATION: HOUSEWIFE APPETITE: NORMAL

DIET: MIXED

BOWEL AND BLADDER: REGULAR KNOWN ALLERGIES: NO ADDICTIONS: NO

FAMILY HISTORY:

NO SIGNIFICANT HISTORY.

GENERAL EXAMINATION :PT IS CONCIOUS , COHERENT AND COOPERATIVE , MODERATLY BUILT AND NOURISHED .NO PALLOR, ICTERUS , CYANOSIS, CLUBBING

,LYMPHADENOPATHY, EDEMA.TEMP - 97.6 FPR- 90 BPMRR- 31 CPMBP- 140/90 MMHGSPO2- 98% AT RAGRBS- 247MG/DL

SYSTEMIC EXAMINATION -

CVS- S1,S2 HEARD,NO MURMURSRESPIRATORY SYSTEM-TRACHEA CENTRAL,VESICULAR SOUNDS HEARDABDOMEN-NO TENDERNESS,DISTENTION,ORGANOMEGALYCNS-NO FOCAL DEFICITS

COURSE AT HOSPITAL

PATIENT OF 66YEARS PRESENTED TO CASUALITY WITH C/O INVOLUNTARY MOVEMENTS OF UPPER LIMBS AND LOWER LIMBS SINCE 1 HR FROTHING FROM MOUTH AND WAS INVESTIGATED FURTHER AND ON EVALUATION WAS DIAGNOSED AS

HYPOGLYCEMIC SEIZURES (RESOLVED)

HYPOGLYCEMIA SECONDARY TO INSULIN AND WAS TREATED CONSERVATIVELY WITH 25% DEXTROSE , GRBS WAS MONITORED.WITHHOLDED INSULIN

ON 01/5/2024 OPHTHALMOLOGY REFERRAL WAS TAKEN I/V/O HYPERTENISVE AND DIABETIC RETINOPATHY CHANGES

IMPRESSION ON FUNDOSCOPY BOTH FUNDUS ARE NORMAL

USG SHOWED INCREASED URINARY BLADDER WALL THICKNESS ? CYSTITIS AND PATIENT WAS STARTED ON IV ANTIBIOTICS.SYMPOTOMS SUBSIDED

NO SEIZURE EPISODE WAS REPORTED

 

HYPOGLYCEMIA RESOLVED

PATIENT IS HEMODYNAMICALLY STABLE AT TIME OF DISCHARGE

Investigation

NameValueRangeNameValueRangeLIVER FUNCTION TEST (LFT) 29-04-2024 10:51:PM Total Bilurubin0.47 mg/dl1-0 mg/dlDirect Bilurubin0.20 mg/dl0.2-0.0 mg/dlSGOT(AST)17 IU/L31-0 IU/LSGPT(ALT)10 IU/L34-0 IU/LALKALINE PHOSPHATASE304 IU/L141-53 IU/LTOTAL PROTEINS5.4 gm/dl8.3-6.4 gm/dlALBUMIN2.4 gm/dl4.6-3.2 gm/dlA/G RATIO0.83RFT 29-04-2024

10:51:PM UREA17 mg/dl50-17 mg/dlCREATININE1.3 mg/dl1.2-0.6 mg/dlURIC ACID5.1 mmol/L6-2.6 mmol/LCALCIUM9.4 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.3 mg/dl4.5-2.5 mg/dlSODIUM138 mmol/L145-136 mmol/LPOTASSIUM2.9 mmol/L.5.1-3.5 mmol/L.CHLORIDE104 mmol/L98-107 mmol/LCOMPLETE URINE EXAMINATION (CUE) 29-04-2024 10:51:PM COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINNilSUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS1-2RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilHBsAg-RAPID29- 04-2024 10:51:PMNegative T3, T4, TSH 30-04-2024 05:29:AM T30.53 ng/ml1.87-0.87 ng/mlT46.48

micro g/dl12.23-6.32 micro g/dlTSH4.88 micro Iu/ml5.36-0.34 micro Iu/mlRFT 01-05-2024 12:14:AM UREA18 mg/dl50-17 mg/dlCREATININE1.4 mg/dl1.2-0.6 mg/dlURIC ACID5.5 mmol/L6-2.6 mmol/LCALCIUM8.5 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.0 mg/dl4.5-2.5 mg/dlSODIUM140 mmol/L145-136 mmol/LPOTASSIUM3.5 mmol/L.5.1-3.5 mmol/L.CHLORIDE104 mmol/L98-107 mmol/LPERIPHERAL SMEAR01-05-2024 03:38:PMRBC : Normocytic normochromic anemia WBC : With in normal limits PLATELET : Adequate RFT 01-05-2024 11:00:PM UREA18 mg/dl50-17 mg/dlCREATININE1.3 mg/dl1.2-0.6 mg/dlURIC ACID5.5 mmol/L6-2.6 mmol/LCALCIUM8.5 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.9 mg/dl4.5-2.5 mg/dlSODIUM141 mmol/L145-136 mmol/LPOTASSIUM3.5 mmol/L.5.1-3.5 mmol/L.CHLORIDE101 mmol/L98-107 mmol/L

HEMOGRAM ON 29/04/2024 HAEMOGLOBIN 9.9 gm/dl

TOTAL COUNT 14,500 cells/cumm NEUTROPHILS 84%

LYMPHOCYTES 09%

EOSINOPHILS 01%

MONOCYTES 06%

BASOPHILS 00 % PCV 29.4 vol %

M C V 83.2 fl M C H 27.9 pg

RBC COUNT 3.54 millions/cum

 

PLATELET COUNT 4.05 lakhs/cu.mm SMEAR

RBC Normocytic normochromic WBC neutrophilic leukocytosis PLATELETS Adequate

HEMOPARASITES No hemoparasites seen IMPRESSION

Normocytic normochromic anemia with neutrophilic leukocytosis 2DECHO ON 30/04/2024 IMPRESSION

NO RWMA MILD LVH + MILD TO MODERATE MR MILD TO MODERATE AR MODERATE TR WITH PAH

SPECS OF CALCIFIED TRICUSPID LEAFLETS NO AS MS

EJECTION FRACTION 62% GOOD LV SYSTOLIC FUNCTION GRADE 1 DIASTOLIC DYSFUNCTION MINIMAL PE +

IVC COLLASPING

USG ABDOMEN 0N 2/5/2024 IMPRESSION

RAISED ECHOGENECITY OF LEFT KIDNEY

MILD HEPATOMEGALY WITH GRADE 2 FATTY LIVER INCREASED URINARY BLADDER WALL THICKNESS ? CYSTITIS

Treatment Given(Enter only Generic Name)

INJ. MONOCEF 1 AMP/IV/BD X 4 DAYS

INJ. IV 25% DEXTROSE INFUSION 15ML/HR TAPERED TAB. TELMA H 40/12.5 PO/OD X 4 DAYS

TAB. THYRONORM 12.5 MCG OD X 4 DAYS SYP. CITRALKA 15ML PO/TID X 3 DAYS IVF 2 NS AT 50ML/HR X 2 DAYS

Advice at Discharge

TAB TELMA H 40/12.5 PO OD X7 DAYS

TAB THYRONORM 12.5 MG OD/8AM BEFORE BREAK FAST X 7 DAYS TAB OROFER XT PO OD X 7 DAYS

STRICT DIABETIC DIET POTASSIUM RICH DIET

Follow Up

REVIEW WITH FBS PLBS SERUM CREATININE AFTER 1 WEEK

First Encounter: 11/15/2023

• Outcome:morbidity

Case 10

https://himajav.blogspot.com/2024/05/75f-htn-hypothyroidism-cad.html

HISTORY

A 75-year-old female was born and raised in a lower socio-economic family along with six siblings. Her education extended only to primary school, after which she discontinued her studies. At the age of 17, she married a non-consanguineous partner. She conceived a year after marriage but experienced a stillbirth. Two years later, she conceived again but had a miscarriage. Three years after that, she successfully gave birth to a healthy girl.

Twenty years ago, her husband died suddenly from cardiac arrest. Following his death, she moved in with her daughter. Six months after her husband’s passing, she developed hypertension, which was followed by diabetes three months later. Fifteen years ago, she lost her elder brother. Six years ago, she presented to our hospital with abdominal pain, nausea, vomiting, and loose stools, and was diagnosed with cholelithiasis, which was managed conservatively.

Two years ago, she experienced shortness of breath lasting ten minutes, and upon visiting our hospital, was diagnosed with heart failure and renal failure.

Patient complains of loss of appetite since 5 days

Associated with constipation

DAILY ROUTINE

6:30am wakes up

6:30-9:30am. Goes to washroom, wash utensils, prepares breakfast 

9:30-10am Breakfast

10:30am-12:30pm. Takes nap

12:30pm wakes up and have lunch, usually rice and curry

2-4:30pm: takes nap

4:30pm: does household chores like washing utensils, folding clothes, vegetable cutting

7:00-9:00pm watch TV serials

9:30pm- Dinner

10:30pm- Bed time

CHIEF COMPLAINTS:

A 75 YEARS OLD FEMALE CAME WITH COMPLAINTS OF PAIN ABDOMEN SINCE 1 WEEK.

 

 

HISTORY OF PRESENT ILLNESS:

THE PATIENT WAS APPARENTLY ASYMPTOMATIC 1 WEEK BACK THEN SHE DEVELOPED PAIN ABDOMEN WHICH IS INSIDIOUS IN ONSET IN HYPOGASTRIUM TWISTING TYPEASSOCIATED WITH BLOATING OF ABDOMEN MORE AFTER EATING ASSOCIATED WITH NAUSEA.

No H/o cough, cold, burning micturition 

No H/o pedal edema, increased or decreased urine output

No H/o orthopnea, PND, palpitations

No H/o loose stools, nausea, vomitings

No h/o fever, headache , giddiness

DIAGNOSIS

HEART FAILURE WITH REDUCED EJECTION FRACTION

CHRONIC KIDNEY DISEASE

ANEMIA OF CHRONIC DISEASE

HYPERTENSION

DIABETES

Summary

Diagnosis

HEART FAILURE WITH REDUCED EJECTION FRACTION(44%) K/C/O DM TYPE 2, HYPERTENSION

ANEMIA OF CHRONIC DISEASS CHRONIC KIDNEY DISEASE -4

Case History and Clinical Findings

CHIEF COMPLAINTS:

A 75 YEARS OLD FEMALE CAME WITH COMPLAINTS OF PAIN ABDOMEN SINCE 1 WEEK.

HISTORY OF PRESENT ILLNESS:

THE PATIENT WAS APPARENTLY ASYMPTOMATIC 1 WEEK BACK THEN SHE DEVELOPED PAIN ABDOMEN WHICH IS INSIDIOUS IN ONSET IN HYPOGASTRIUM TWIOSTING TYPE ASSOCIATED WITH BLOATING OF ABDOMEN MORE AFTER EATING ASSOCIATED WITH NAUSEA.

NO H/O CHILLS , COUGH ,COLD. NO H/O BURNING MICTURITION.

NO H/O CHEST PAIN , PALPITATIONS, BREATHLESSNESS, ORTHOPNEA, PND

PAST HIOSTORY:

K/C/O T2DM ON HAI SINCE 18 YEARS HTN ON TAB MET-12.5 MG+ CINOD 10MG

CKD SECONDARY TO DIABETIC NEPHROPATHY

 

HFPEF

TREATMENT HISTORY:

ON HAI 6U-4U-6U SINCE 18 YEARS

OM TAB MET -XL 12.5MG + CINOD 10MG PERSONAL HISTORY :

DIET - MIED APPETITE - NORMAL SLEEP - ADEQUATE

BOWEL& BLADDER MOVEMENTS - REGULAR ADDICTIONS - NIL

GENERAL PHYSICAL EXAMINATION :

PATIENT IS CONSCIOUS , COHERENT &COOPERATIVE , WELL ORIENTED TO TIME AND PLACE .

NO PALLOR/ ICTERUS / CYANOSIS / CLUBBING / LYMPHADENOPATHY / OEDEMA. VITALS :

BP ; 120/70MM HG PR : 78 BPM

RR : 18 CPM TEMP ; 98.6F SPO2 : 98% @ RA GEBS- 184 MG/ DL

SYSTEMIC EXAMINATION :

CNS : POWER:

UL LL

R 5/5 5/5 L 5/5 5/5

REFLEXES : B T S K A

R +2 +2 + 1 +2 +

L +2 +2 +1 +2 +

 

CVS :

S1, S2 HEARD , NO MURMURS

RS :

BAE + , NVBS

P/A :

SOFT , NON TENDER

COURSE IN THE HOSPITAL :

75 Y OLD LADY CAME TO OPD WITH C/O OF PAIN ABDOMEN SINCE 1 WEEK. PATIENT IS A K/C/O T2DM SINCE 18 YEARS, HTN ON TAB.MET-12.5 MG+ CINOD 10MG,CKD SECONDARY TO DIABETIC NEPHROPATHY,HFPEF.PATIENT WAS TREATED CONSERVATIVELY AND ACCORDINGLY .PATIENT IS BEING DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION .

Investigation

POST LUNCH BLOOD SUGAR27-05-2024 11:38:AM169 mg/dl140-0 mg/dlBLOOD UREA27-05- 2024 11:38:AM64 mg/dl50-17 mg/dlSERUM CREATININE27-05-2024 11:38:AM3.2 mg/dl1.2-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) 27-05-2024 11:38:AM SODIUM139 mmol/L145-136

mmol/LPOTASSIUM4.4 mmol/L5.1-3.5 mmol/LCHLORIDE102 mmol/L98-107 mmol/LLIVER FUNCTION TEST (LFT) 27-05-2024 11:38:AM Total Bilurubin0.67 mg/dl1-0 mg/dlDirect Bilurubin0.18 mg/dl0.2-0.0 mg/dlSGOT(AST)10 IU/L31-0 IU/LSGPT(ALT)10 IU/L34-0 IU/LALKALINE PHOSPHATASE218 IU/L141-53 IU/LTOTAL PROTEINS6.4 gm/dl8.3-6.4 gm/dlALBUMIN3.69

gm/dl4.6-3.2 gm/dlA/G RATIO1.36HBsAg-RAPID27-05-2024 11:38:AMNegative Anti HCV Antibodies

- RAPID27-05-2024 11:38:AMNon Reactive COMPLETE URINE EXAMINATION (CUE) 27-05-2024 11:52:PM COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN+++SUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS4-5EPITHELIAL CELLS3-4RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNil

HEMOGRAM :

HB - 8.2 GM/DL

TLC - 4900 CELLS / CUMM ;N/L/E/M/B = 75/18/6/5/0 % PCV - 25.1 VOL %

MCV - 79.9 FL

 

MCH - 26.1 PG MCHC - 32.7 %

RBC - 3.14 MILLION/ CU MM PLATELET - 1.40 LAKHS / CU MM

SMEAR : NORMOCYTIC NORMOCHROMIC CREAT CLEARENCE :10ML /MIN

CGFR: 15ML/MIN

USG WAS DONE ON: 27/5/24

IMPRESSION : GRADE 2 RPD CHANGES IN RIGHT KIDNEY GRADE 3 RPD CHANGES IN LEFT KIDNEY

BILATERAL RENAL CORTICAL CYSTS 2D ECHO WAS DONE ON: 27/5/24 EF:44%

FS:22%

MODERATE MR+ ,MILD AR+, TRIVIAL TR+ RWMA+ , RCA AND LAD HYPOKINESIA ; NOAS/MS MODERATE LV DYSFUNCTION+

GRADE 1 DIASTOLIC DYSFUNCTION+ ; NO PAH/PE/LV CLOT

Treatment Given(Enter only Generic Name)

1) INJ HAI SC/TID

2) TAB CINOD 10 MG PO/OD 1-0-1

3) TAB MET XL 12.5 MGPO/OD

4) TAB NODOSIS 500MG PO/OD

5) TAB ECOSPRIN 75 GOLD PO/HS 6)TAB DYTOR 5MG PO/BD

7) TAB PAN 40 MG PO/OD

8) TAB ONDANSETRON 4MG PO/TID

9) TAB BUSCOPAN 1 TAB PO/SOS

10) INJ EPO 4000 IU S/C TWICE WEEKLY

11) INJ ZOFER 4 MG /IV/SOS

12) TAB CILNIDIPINE 10 MGPO/OD

13) TAB METOPROLOL 12.5 MG PO/OD

14) TAB SODABICARBONATE 500MG PO/OD

 

Advice at Discharge

1) INJ HAI SC/TID 6U-4U-6U (PREMEAL)

2) TAB CILNIDIPINE 10 MGPO/OD 1-0-0 X TO CONTINUE

3) TAB METOPROLOL 12.5 MG PO/OD 1-0-0 C XTO CONTINUE

4) TAB SODABICARBONATE 500MG PO/OD 1-0-0 X 1WEEK

5) TAB ECOSPRIN 75 + CLOPIDOGREL 75 + ATORVAS PO/HS 0-0-1 X1WEEK

6) TAB TORSEMIDE 10 MG PO/BD 8AM -4PM X1WEEK 7)TAB PAN 40MG PO/OD 1-0-0 X 1WEEK

8) TAB BUSCOPAN 1 TAB PO.SOS

9) SYP GUTCLEAR PO/HS 2-3 TSP X 3DAYS 10)TAB ONDEM 4MG PO/SOS

First Encounter: 03/13/2024

• Outcome: morbidity

Case 11

60F, Acute Pulmonary Edema, Diabetes, HTN  

    [Link](https://userdrivenhealthcare.blogspot.com/2024/04/cbble-case-report-60-year-old-woman.html?m=1)

Diagnosis

TYPE 2 RESPIRATORY FAILURE SECONDARY TO ? ATYPICAL GBS WITH ISOLATED RESPIRATORY PARALYSIS

HEART FAILURE WITH PRESERVED EJECTION FRACTION

COMMUNITY ACQUIRED PNEUMONIA IN RIGHT MIDDLE AND LOWER LOBE (RESOLVED) B/L GRADE II BEDSORES

KNOWN CASE OF HYPERTENSION SINCE 5 YEARS KNOWN CASE OF DIABETES SINCE 5 YEARS

Case History and Clinical Findings

50 YEAR UNEMPLOYED RESIDENT OF NAKREKAL WAS BROUGHT TO CASUALTY WITH COMPLAINTS OF

FEVER SINCE 5 DAYS COUGH SINCE 4 DAYS

DIFFICULTY BREATHING SINCE 1 DAY

PATIENT WAS APPARENTLY ASYMPTOMATIC UNTIL 5 DAYS AGO THEN HAD COMPLAINTS OF GENERALISED FEVER LOW GRADE NOT ASSOCIATED WITH CHILLS AND RIGOR NO DIURNAL VARIATIONS, INTERMITTENT, GRADUALLY PROGRESSIVE ASSOCIATED WITH COUGH- PRODUCTIVE WHITISH SPUTUM THICK CONSISTENCY, MUCOID, NON FOUL SMELLING, NON BLOOD STAINED, SHORTNESS OF BREATH GRADE 4 MMRC SINCE ONE DAY ,GENERALISED WEAKNESS.

NO COMPLAINS OF ORTHOPNEA,PALPITATIONS,PROFUSE SWEWATING

 

NO COMPLAINS OF BURNING MICTURITION, INCREASED OR DECREASED URINE OUTPUT, PEDAL EDEMA

NO COMPLAINS OF LOOSE STOOLS, NAUSEA, VOMITINGS NO HISTORY OF ANY MOSQUITO BITE, SCOPRION BITE

PAST HISTORY

HISTORY OF HOSPITALIZATION WITH?DENGUE ?SEPSIS 8 MONTHS AGO KNOWN CASE OF HYPERTENSION SINCE 5 YEARS ON UNKNOWN MEDICATION

KNOWN CASE OF DIABETES ON TAB METFORMIN 500MG AND TAB GLIMIPERIDE 1 MG OD NOT A KNOWN CASE OF TB,THYROID,ASTHMA,CAD,CVA

PERSONAL HISTORY

LOSS OF APPETITE SINCE THREE DAYS DIET-NON VEGETERIAN

BOWEL-CONSTIPATION SINCE THREE DAYS MICTURITION- NORMAL

NO KNOWN ALLERGIES OCCASIONAL ALCOHOLIC NON SMOKER

FAMILY HISTORY

NO SIGNIFICANT FAMILY HISTORY

MENSTRUAL HISTORY HYSTERECTOMY DONE 29YRS AGO

GENERAL EXAMINATION

NO PALLOR ICTERUS CYANOSIS CLUBBING AND LYMPHAEDENOPATHY VITALS AT TIME OF ADMISSION

TEMP-100F PR: 80BPM

BP:130/80MMHG RR: 20CPM

 

SPO2- 40% AT RA GRBS-221MG/DL

R/S: BILATERAL AIR ENTRY PRESENT CREPTS IN RIGHT MAMMARY, LEFT IAA,ISA CVS: S1S2 HEARD NO MURMURS

P/A: SOFT, NON TENDER CNS: NFND

COURSE IN THE HOSPITAL

THIS IS A CASE OF 50YR OLD FEMALE CAME WITH COMPLAINTS OF FEVER, SHORTNESS OF BREATH SINCE 4DAYS AND FACIAL PUFFINESS SINCE 3DAYS, WAS EVALUATED INITIALLY AND NECESSARY INVETIGATIONS WERE DONE. AND AS ABG WAS DONE, WHICH SHOWED TYPE II RESPIRATORY FAILURE WITH FLAPPING TREMORS SEEN IN PATIENT SECONDARY ?CO2 NARCOSIS, PATIENT WAS INITIALLY KEPT ON NIV. BUT AS THERE IS NO IMPROVEMENT IN ABG AND AS STILL CO2 LEVELS ARE INCREASING ON NIV, PATIENT WAS INTUBATED I/V/O TYPE II RESPIRATORY FAILURE, AND ON FURTHER INVESTIGATIONS DONE AND HRCT SHOWED CONSOLIDATION WITH ,MILD BRONCHIECTASIS IN BASAL SEGMENT OF RIGHT LOWER LOBE WAS DIAGNOSED WITH COMMUNITY ACQUIRED PNEUMONIA OF RIGHT MIDDLE AND LOWER LOBE ,HEART FAILURE WITH PRESERVED EJECTION FRACTION WITH A K/C/O T2DM &HYPERTENSION SO ANTIBIOTICS ,DIURETICS , IV FLUIDS AND OTHER SYMPTOMATIC AND SUPPORTIVE TREATMENT WAS GIVEN. DAY 3 PATIENT WAS STARTED WEANING TRIAL AS WEANING CRITERIA WAS MET,BUT COULDNT BE EXTUBATED BECAUSE OF RESPIRATORY DISTRESS AND HYPERCAPNIA WHEN PATIENT IS SHIFTED TO CPAP SO AGAIN SHIFTED BACK TO ACMV AND CONTINUED ON MV SUPPORT. PATIENT WAS EXTUBATED ON DAY 9 OF ADMISSION AS SHE IS COMPLETELY MAINTAINIG ON T PEICE WITHOUT ANY RESPIRATORY DISTRESS OR ANY ABG ABNORMALITIES AND COMPLETELY MET THE EXTUBATION CRITERIA WITH GCS OF E4VTM6. IMMEDIATELY AFTER 30MINS OF EXTUBATION, PATIENT HAD A SEIZURE EPISODE AND AFTER 1HR OF SEIZURE EPISODES, PATIENT DEVELOPED BRADYCARDIA AND WENT INTO CARDIAC ARREST FOLLOWED BY WHICH ROSC ACHIEVED AFTER 1 CYCLE OF CPR. POST REVIVAL AS PATIENT HAD AN EPISODE OF VENTRICULAR TACHYCARDIA, ANTI ARRHYTHMIC MEDICATION WERE GIVEN AND PATIENT WAS RE- INTUBATED. AS THERE IS A NEED A NEED FOR PROLONGED VENTILATOR SUPPORT, PERCUTANEOUS TRACHEOSTOMY WAS PLANNED AND DONE ON DAY 11 OF ADMISSION. THE PATIENT IS NOW ON TRACHEOSTOMY AND ON OTHER CONSERVATIVE MANAGEMENT WITH IV ANTIBIOTICS, ANTIPYRETICS, ANTIEPILEPTICS AND OTHER SUPPORTIVE MANAGEMENT.AS PATIENT IS IMPROVING WEANE OFF TRAIL WAS STARTED AND PATIENT IS BEING TREATED WITH INTERMITTENT CPAP AND OXYGEN SUPPORT. AS SATURATIONS WERE MAINTAINED TRACHEOSTOMY TUBE CAPPING DONE FOR REMOVAL AND OBSERVED 24HRS .NO HYPOXIA/RESPIRATORY DISTRESS WERE THERE,PATIENT IS HEMODYNAMICALLY STABLE WITH GCS E4V5M6 AND ABG WAS NORMAL SO TRACHEOSTOMY TUBE DECANULATED /REMOVED ON DAY22 DECANNULATIION OF TRACHEOSTOMY TUBE WAS DONE AND PATIENT IS TRAINED TO DO SPIROMETRY BREATHING EXERCISE TO INCREASE LUNG COMPLIANCE.ON DAY 6 PATIENT DEVELOPED B/L GRADE I BEDSORE INITIALLY UNILATERL BUTTOCK THEN BILATERAL BUTTOCK GRADE II BEDSORE FOR WHICH REGURAL DRESSING WAS DONE AND VAC DRESSING WAS DONE. CULTURES FROM BEDSORE WERE SENT AND ARE NEGATIVE. PLASTIC SURGEON OPINION WAS TAKEN FOR THE SAME AND ADVISED NO ACTIVE SURGICAL INTERVENTION, GOOD NUTRITIOUS DIET .PATIENT HAD DEVELOPED FEVER SPIKES FOR WHICH ANTIBIOTICS WAS STARTED. AS PATIENT IS HEMODYNAMICALLY STABLE PATIENT IS DISCHARGED ON 8/04/24 ON DAY 26 WITH HOME OXYGEN AND FOLLOWING ADVICE AT DISCHARGE.

Investigation HEMOGRAM ON 13/3/24 ON 13/3/24

HB 14

TLC 14000

PLT 2.08

ON 15/3/24 HB 13.1

TLC 10 800

PLT 1.50

ON 16/3/24 HB 13.6

TLC 16000

PLT 1.5 ON 17/3/24 HB 11.9

TLC11 300

PLT 1.20

 

ON 18/3/24 HB 12.7 TLC12500 PLT1.20 ON 19/3/24 HB 12.0

TLC 9300

PLT 1.20 ON 20/3/24 HB 11.2

TLC 7400

PLT 1.35 ON 22/3/24 HB 11.3

TLC 8600

PLT 2.43 ON 23/3/24 HB 11.1

TLC 6300

PLT 3.14 ON 24/3/24 HB 11.3

TLC 7500

PLT 3.01 ON 27/3/24 HB 12.0

TLC 7200

PLT 3.02

RAPID HBSAG NEGATIVE HIV 1 AND 2 NEGATIVE

RAPID HCV ANTIBODIES NEGATIVE

RFT ON 13/3/24

 

UREA 42

CREAT 0.7

Na 142

K 4.0

CL 99

I CA 1.15

RFT ON 15/3/24 UREA 30

CREAT 0.9

Na 136

K 3.9

CL 101

RFT ON 15/3/24 UREA 44

CREAT 0.7

Na 143

K 3.6

CL 99

RFT ON 17/3/24 UREA 39

CREAT 0.8

Na 141

K 3.5

CL 96

RFT ON 20/3/24 UREA 18

CREAT 0.6

URIC ACID 2.0

Na 139

K 3.4

CL 96

 

RFT ON 29/3/24 UREA 29

CREAT 0.7

URIC ACID 3.7

CA 10.0

P 4.3

Na 139

K 3.8

CL 98

LFT ON 13/3/24 TB 1.33

DB 0.46

AST 30

ALT 64

ALP 205

TP 7.9

ALB 3.60

A/G 0.84

LFT ON 17/3/24 TB 2.86

DB 0.91

AST 94

ALT 55

ALP 186

TP 5.6

ALB 2.63

A/G 0.89

LFT ON 20/3/24 TB 1.62

DB 0.44

AST 99

 

ALT 78

ALP 202

TP 5.3

ALB 2.5

A/G 0.9

RBS 193

LIPID PROFILE

TOTAL CHOLESTEROL 219

TG 326

HDL 42

LDL 130

VLDL 65.2

RBS ON 14/3/24 122 HBA1C 7.0

THYROID PROFILE ON 20/3/24 T3 0.62

T4 11.26

TSH 3.98

ABG - 13/3/24 PH-7.295 PCO2-96 PO2-69.2 SO2-92.6

CHCO3 [PST]C 36.7

ABG - 14/3/24 POST INTUBATION PH-7.363

PCO2- 82.8

 

PO2-68 SO2-88.6

CHCO3 [PST]C 44.8 ABG - EXTUBATION PH-7.129

PCO2-65 PO2-84 SO2-92.6

CHCO3 [PST]C 20.7. ABG - REINTUBATION PH-7.431

PCO2-39.8 PO2-82.7 SO2-96.9

CHCO3 [PST]C 26

ABG - AFTER TRACHEOSTOMY PH-7.33

PCO2-47.9 PO2- 76.6 SO2-94.2

CHCO3 [PST]C 23.8

ABG - 26/3/24 ON T PIECE 1 L OF O2 PH-7.342

PCO2-44 PO2-64.8 SO2-92.9

CHCO3 [PST]C 23.2 ABG - 27/3/24

PH-7.472 PCO2-27.7 PO2-54.8 SO2-95

CHCO3 [PST]C 20 ABG - 28/3/24

 

PH-7.461 PCO2-42.7 PO2-57.2 SO2-90.9

CHCO3 [PST]C 30 ABG - 7/4/24

PH-7.445 PCO2-42.3 PO2-61.4 SO2-93.4

CHCO3 [PST]C 28.6

2DECHO VPC +

NO RWMA

MILD AR TRIVIAL TRTRIVIAL MR SCLEROTIC AV NO AS/MS

EF 64 RVSP 36MMHG

GOOD LV SYSTOLIC FUNCTION GRADE I DIASTOLIC FUNCTION IVC 0.8CM

MINIMAL PE

HRCT CHEST

CONSOLIDATION WITH MILD BRONCHIECTASIS IN BASAL SEGMENT OF RIGHT LOWER LOBE BILATERAL MILD LOCULATED PLEURAL EFFUSION [R.L] F/S/O INFECTIVE ETIOLOGY

ET CULTURE- NO GROWTH IS SEEN

BLOOD C/S - NO GROWTH IS SEEN AFTER 1 WEEK OF AEROBIC INTUBATION AND 48 HRS OF AEROBIC INTUBATION

WOUND SWAB C/S - NO GROWTH IS SEEN

USG CHEST - B/L MILD PLEURAL EFFUSION ,CONSOLIDATORY CHANGES IN RIGHT LUNG USG ABDOMEN AND PELVIS GB SLUDGE

MILD IHBRD

 

PROMINENT CBD

RAISED ECHOGENECITY OF B/L KIDNEYS POST CPR 2D ECHO (CPR DONE ON 21/3/24) NO RWMA

TRIVIAL TR,TRIVIAL AR,TRIVIAL MR MAC,SCLEROTIC AV,NO AS/MS EF= 64%,RVSP= 35MMHG

GOOD LV SYSTOLIC FUNCTION GRADE I DIASTOLIC DYSFUNCTION IVC SIZE (0.9CMS) COLLAPSING

Treatment Given(Enter only Generic Name)

INJ.AUGMENTIN 1.2 GM IV/TID X 7 DAYS INJ. FENTANYL 2 AMP + 46 ML NS

INJ. ATRACURIUM 2 AMP + 45 ML NS INJ.LEVOFLOXACIB X 6 DAYS

INJ.HUMAN ACTRAPID INSULIN S/C TID PREMEALS ACC TO GRBS INJ.HYDROCORT 100MG IV OD

INJ.LASIX 20 MG IV TID IF SBP >100MMHG TAB.GLYCOPYROLATE 0.5 MG PO/TID TAB.HIFENAC SP PO/BD

TAB.FLUVIR 75MG X 6 DAYS TAB.AZITHROMYCIN X 7 DAYS TAB.MONOCEF X 8 DAYS TAB.PAN D 40MG PO/OD TAB.PCM 650 MG PO/BD TAB.PULMOCLEAR PO/BD TAB.MONTEK LC PO/HS TAB.BENFOMET PLUS PO/OD TAB .ULTRACET 1/2 TAB PO/BD TAB.TUS-MD PO/TID SYP.GRILINCTUS 15ML PO/TID SYP.MUCAINE GEL 15ML PO/TID

NEB WITH MUCOMIST 8 TH HRLY , DUOLIN-6TH HOURLY , BUDECORT- 8TH HRLY DICLOFENAC TD PATCH BD

 

OINT THROMBOPHEBE FOR L/A OINT ZYTEE GEL FOR L/A GRBS 7 POINT PROFILE

SPIROMETRY BREATHING EXERCISE CHEST PHYSIOTHERAPY

ET SUCTIONING POSITION CHANGE BED SORE DRESSING DVT STOCKING

AIR BED

Advice at Discharge

TAB AUGMENTIN 625MG PO BD 1-0-1 X 4 DAYS TAB.GLYCOPYROLATE 0.5 MG PO/TID X 3DAYS TAB LEVIPIL 500MG BD X 3 MONTHS

TAB METFORMIN 500MG PO/BD TO CONTINUE TAB.PAN D PO/OD X 5DAYS

TAB DYTOR PLUS 10/50 PO/OD 1-0-0 TO CONTINUE TAB DYTOR 10 MG PO/OD 0-0-1 TO CONTINUE

SYP CITAL UTI 20ML IN 1 GLASS OF WATER PO/TID 1-1-1 X 5 DAYS TAB DOLO 650MG PO/BD X 3 DAYS

TAB.PULMOCLEAR PO/BD X 7DAYS TAB.MONTEK LC PO/HS X 5DAYS TAB.BENFOMET PLUS PO/ODX 7 DAYS FOROCORT 200MCG 2 PUFFS BD

HOME OXYGEN @ 1-2LITS WHILE SLEEPING SPIROMETRY BREATHING EXERCISE

DAILY BEDSORE DRESSING WITH MEGAHEAL OINT AND CUTICELL SOFT DIET

AMBULATION

First Encounter: 05/27/2024

• Outcome: mortality 

Case 12

https://himajav.blogspot.com/2024/05/75f-hfref-ckd-htn-dm.html

HISTORY

A 75-year-old female was born and raised in a lower socio-economic family along with six siblings. Her education extended only to primary school, after which she discontinued her studies. At the age of 17, she married a non-consanguineous partner. She conceived a year after marriage but experienced a stillbirth. Two years later, she conceived again but had a miscarriage. Three years after that, she successfully gave birth to a healthy girl.

Twenty years ago, her husband died suddenly from cardiac arrest. Following his death, she moved in with her daughter. Six months after her husband’s passing, she developed hypertension, which was followed by diabetes three months later. Fifteen years ago, she lost her elder brother. Six years ago, she presented to our hospital with abdominal pain, nausea, vomiting, and loose stools, and was diagnosed with cholelithiasis, which was managed conservatively.

Two years ago, she experienced shortness of breath lasting ten minutes, and upon visiting our hospital, was diagnosed with heart failure and renal failure.

Patient complains of loss of appetite since 5 days

Associated with constipation

DAILY ROUTINE

6:30am wakes up

6:30-9:30am. Goes to washroom, wash utensils, prepares breakfast 

9:30-10am Breakfast

10:30am-12:30pm. Takes nap

12:30pm wakes up and have lunch, usually rice and curry

2-4:30pm: takes nap

4:30pm: does household chores like washing utensils, folding clothes, vegetable cutting

7:00-9:00pm watch TV serials

9:30pm- Dinner

10:30pm- Bed time

CHIEF COMPLAINTS:

A 75 YEARS OLD FEMALE CAME WITH COMPLAINTS OF PAIN ABDOMEN SINCE 1 WEEK.

 

 

HISTORY OF PRESENT ILLNESS:

THE PATIENT WAS APPARENTLY ASYMPTOMATIC 1 WEEK BACK THEN SHE DEVELOPED PAIN ABDOMEN WHICH IS INSIDIOUS IN ONSET IN HYPOGASTRIUM TWISTING TYPEASSOCIATED WITH BLOATING OF ABDOMEN MORE AFTER EATING ASSOCIATED WITH NAUSEA.

No H/o cough, cold, burning micturition 

No H/o pedal edema, increased or decreased urine output

No H/o orthopnea, PND, palpitations

No H/o loose stools, nausea, vomitings

No h/o fever, headache , giddiness

DIAGNOSIS

HEART FAILURE WITH REDUCED EJECTION FRACTION

CHRONIC KIDNEY DISEASE

ANEMIA OF CHRONIC DISEASE

HYPERTENSION

DIABETES

Discharge summary

Diagnosis

HEART FAILURE WITH REDUCED EJECTION FRACTION(44%) K/C/O DM TYPE 2, HYPERTENSION

ANEMIA OF CHRONIC DISEASS CHRONIC KIDNEY DISEASE -4

Case History and Clinical Findings

CHIEF COMPLAINTS:

A 75 YEARS OLD FEMALE CAME WITH COMPLAINTS OF PAIN ABDOMEN SINCE 1 WEEK.

HISTORY OF PRESENT ILLNESS:

THE PATIENT WAS APPARENTLY ASYMPTOMATIC 1 WEEK BACK THEN SHE DEVELOPED PAIN ABDOMEN WHICH IS INSIDIOUS IN ONSET IN HYPOGASTRIUM TWIOSTING TYPE ASSOCIATED WITH BLOATING OF ABDOMEN MORE AFTER EATING ASSOCIATED WITH NAUSEA.

NO H/O CHILLS , COUGH ,COLD. NO H/O BURNING MICTURITION.

NO H/O CHEST PAIN , PALPITATIONS, BREATHLESSNESS, ORTHOPNEA, PND

PAST HIOSTORY:

K/C/O T2DM ON HAI SINCE 18 YEARS HTN ON TAB MET-12.5 MG+ CINOD 10MG

CKD SECONDARY TO DIABETIC NEPHROPATHY

 

HFPEF

TREATMENT HISTORY:

ON HAI 6U-4U-6U SINCE 18 YEARS

OM TAB MET -XL 12.5MG + CINOD 10MG PERSONAL HISTORY :

DIET - MIED APPETITE - NORMAL SLEEP - ADEQUATE

BOWEL& BLADDER MOVEMENTS - REGULAR ADDICTIONS - NIL

GENERAL PHYSICAL EXAMINATION :

PATIENT IS CONSCIOUS , COHERENT &COOPERATIVE , WELL ORIENTED TO TIME AND PLACE .

NO PALLOR/ ICTERUS / CYANOSIS / CLUBBING / LYMPHADENOPATHY / OEDEMA. VITALS :

BP ; 120/70MM HG PR : 78 BPM

RR : 18 CPM TEMP ; 98.6F SPO2 : 98% @ RA GEBS- 184 MG/ DL

SYSTEMIC EXAMINATION :

CNS : POWER:

UL LL

R 5/5 5/5 L 5/5 5/5

REFLEXES : B T S K A

R +2 +2 + 1 +2 +

L +2 +2 +1 +2 +

 

CVS :

S1, S2 HEARD , NO MURMURS

RS :

BAE + , NVBS

P/A :

SOFT , NON TENDER

COURSE IN THE HOSPITAL :

75 Y OLD LADY CAME TO OPD WITH C/O OF PAIN ABDOMEN SINCE 1 WEEK. PATIENT IS A K/C/O T2DM SINCE 18 YEARS, HTN ON TAB.MET-12.5 MG+ CINOD 10MG,CKD SECONDARY TO DIABETIC NEPHROPATHY,HFPEF.PATIENT WAS TREATED CONSERVATIVELY AND ACCORDINGLY .PATIENT IS BEING DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION .

Investigation

POST LUNCH BLOOD SUGAR27-05-2024 11:38:AM169 mg/dl140-0 mg/dlBLOOD UREA27-05- 2024 11:38:AM64 mg/dl50-17 mg/dlSERUM CREATININE27-05-2024 11:38:AM3.2 mg/dl1.2-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) 27-05-2024 11:38:AM SODIUM139 mmol/L145-136

mmol/LPOTASSIUM4.4 mmol/L5.1-3.5 mmol/LCHLORIDE102 mmol/L98-107 mmol/LLIVER FUNCTION TEST (LFT) 27-05-2024 11:38:AM Total Bilurubin0.67 mg/dl1-0 mg/dlDirect Bilurubin0.18 mg/dl0.2-0.0 mg/dlSGOT(AST)10 IU/L31-0 IU/LSGPT(ALT)10 IU/L34-0 IU/LALKALINE PHOSPHATASE218 IU/L141-53 IU/LTOTAL PROTEINS6.4 gm/dl8.3-6.4 gm/dlALBUMIN3.69

gm/dl4.6-3.2 gm/dlA/G RATIO1.36HBsAg-RAPID27-05-2024 11:38:AMNegative Anti HCV Antibodies

- RAPID27-05-2024 11:38:AMNon Reactive COMPLETE URINE EXAMINATION (CUE) 27-05-2024 11:52:PM COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN+++SUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS4-5EPITHELIAL CELLS3-4RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNil

HEMOGRAM :

HB - 8.2 GM/DL

TLC - 4900 CELLS / CUMM ;N/L/E/M/B = 75/18/6/5/0 % PCV - 25.1 VOL %

MCV - 79.9 FL

 

MCH - 26.1 PG MCHC - 32.7 %

RBC - 3.14 MILLION/ CU MM PLATELET - 1.40 LAKHS / CU MM

SMEAR : NORMOCYTIC NORMOCHROMIC CREAT CLEARENCE :10ML /MIN

CGFR: 15ML/MIN

USG WAS DONE ON: 27/5/24

IMPRESSION : GRADE 2 RPD CHANGES IN RIGHT KIDNEY GRADE 3 RPD CHANGES IN LEFT KIDNEY

BILATERAL RENAL CORTICAL CYSTS 2D ECHO WAS DONE ON: 27/5/24 EF:44%

FS:22%

MODERATE MR+ ,MILD AR+, TRIVIAL TR+ RWMA+ , RCA AND LAD HYPOKINESIA ; NOAS/MS MODERATE LV DYSFUNCTION+

GRADE 1 DIASTOLIC DYSFUNCTION+ ; NO PAH/PE/LV CLOT

Treatment Given(Enter only Generic Name)

1) INJ HAI SC/TID

2) TAB CINOD 10 MG PO/OD 1-0-1

3) TAB MET XL 12.5 MGPO/OD

4) TAB NODOSIS 500MG PO/OD

5) TAB ECOSPRIN 75 GOLD PO/HS 6)TAB DYTOR 5MG PO/BD

7) TAB PAN 40 MG PO/OD

8) TAB ONDANSETRON 4MG PO/TID

9) TAB BUSCOPAN 1 TAB PO/SOS

10) INJ EPO 4000 IU S/C TWICE WEEKLY

11) INJ ZOFER 4 MG /IV/SOS

12) TAB CILNIDIPINE 10 MGPO/OD

13) TAB METOPROLOL 12.5 MG PO/OD

14) TAB SODABICARBONATE 500MG PO/OD

 

Advice at Discharge

1) INJ HAI SC/TID 6U-4U-6U (PREMEAL)

2) TAB CILNIDIPINE 10 MGPO/OD 1-0-0 X TO CONTINUE

3) TAB METOPROLOL 12.5 MG PO/OD 1-0-0 C XTO CONTINUE

4) TAB SODABICARBONATE 500MG PO/OD 1-0-0 X 1WEEK

5) TAB ECOSPRIN 75 + CLOPIDOGREL 75 + ATORVAS PO/HS 0-0-1 X1WEEK

6) TAB TORSEMIDE 10 MG PO/BD 8AM -4PM X1WEEK 7)TAB PAN 40MG PO/OD 1-0-0 X 1WEEK

8) TAB BUSCOPAN 1 TAB PO.SOS

9) SYP GUTCLEAR PO/HS 2-3 TSP X 3DAYS 10)TAB ONDEM 4MG PO/SOS

First Encounter: 05/22/2024

• Outcome: morbidity

Case 13

https://himajav.blogspot.com/2024/05/thankyou-govardhini-chief-complaints.html

Case 13

Cheif complaints 

A 45 year old female came to GM opd with chief complaints of Neckpain since 10 days and low grade fever since 10 days 

Patient was resident of guntur where she lives with her parents and her 3 siblings,she is a 3rd child,Did not go to school and entered handloom work at 10years of age.

She was married at age of 15years and and by the age of 17 she had first child and after 3 years of 1st child birth she got concieved had spontaneous abortion at 6months of gestational age due to work pressure and increased stress.3 years after the second pregnancy she had 3rd child and at 3 months of age the baby died due to fever.she felt depressed at worried about that event.After 3 years from that event she gave birth to 4th child with no health issues.

Since then she is doing fine with her life.

4 years ago she had h/o generalised weakness for which she went to local hospital and diagnosed of having hypertension and started on Tab.Losartan(50mg)+Tab.Hydrochlorthiazide(12.5 mg) and after starting that medication she felt better till 2 months

She is c/o neck pain since 10 days 

2 months back then she developed neck pain insidious in onset gradually progressive and aggravated since past 10 days. 

Restriction of movements+.

Neck Pain aggravates on flexion and extension of neck.

No h/o trauma. 

Low grade fever not associated with chills and rigors since 10 days,Intermittent in nature.

No h/o sob,cough,sore throat,Abdominal pain,vomitings,loose stools, Tingling of b/l upper limbs+.

Past History :

K/c/o htn since 4 years and on medication T. losertan 50 mg+Hydrochlorothiazide 12.5 mg po/od 

N/k/c/o DM, thyroid,CVA,epilepsy, Asthma,CAD

Personal History :

Appetite -Normal

Diet -Mixed

Sleep -Adequate 

Bowel and Bladder -Normal and Regular

Addictions -None

Daily Routine:

Patient is a Weaver by occupation. She works at her own house.

She wakes up by 6 am in the morning. She has her breakfast around 8 am. Then she starts her work by 9am. She works till 1pm. Then she has her Lunch by 2pm and sleeps for an hour. She continues her work till 6pm. She then has her dinner by around 8pm and goes to sleep by 10 pm.

The Daily Routine of the patient is disturbed due to severe neck pain since 10 days.

On General examination 

Patient is concious coherent cooperative 

Well oriented to time place person 

Moderately build and nourished

No Pallor ,Icterus ,cyanosis ,clubbing , koilonychia ,lymphadenopathy

Bilateral Pedal Edema +

Vitals 

Temperature – Afebrile ( 98.6 F )

Pulse rate – 80 bpm , regular 

Respiratory rate – 16 cpm

BP – 140/90 mm Hg 

SPO2 – 98% on room air  

GRBS – 256 mg/dl

Systemic Examination:

CVS- S1 S2 heard

RS- BLAE +

P/A- Soft,NT BS+

CNS:

HMF - Intact 

Speech – Normal 

Kernigs sign - Negative 

Brudzunski sign - Negative

Motor and sensory system – Normal 

Reflexes – Normal 

Cranial Nerves – Intact 

Gait – Normal

Cerebellum – Normal  

GCS Score – 15/15

Summary

Diagnosis

NECK PAIN- CERVICA RADICUOPATHY WITH PARASPINAL SPASM K/C/O HTN SINCE 4 YEARS WITH PERIPHERAL VERTIGO SECONDARY TO VERTEBRO BASILAR INSUFFICIENCY WITH DENOVO THYROID DISEASE (HYPOTHYROIDISM) WITH LEFT CERVICAL LYMPHADENOPATHY WITH DENOVO DM 2 WITH MIGRAINE

Case History and Clinical Findings

C/O NECK PAIN SINCE 10 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTS AGO THEN SHE DEVELOPED NECK PAIN OF INSIDIOUS ONSET GRADUALLY PROGRESSIVE AND AGGRAVATED SINCE PAST 10 DAYS. RESTRICTIPON OF MOVEMENTS PRESENT, PAIN AGGRAVATES ON FLEXION AND EXTENSION OF NECK.

LOW GRADE FEVER IS PRESENT NOT ASSOCIATED WITH CHILLS AND RIGORS SINCE 10 DAYS.

NO H/O COUGH, SOB, COLD, SORE THROAT, ABDOMINAL PAIN, VOMITINGS, LOOSE STOOLS, TINGLING OF BILATERAL UPPER LIMB.

NO H/O TRAUMA PAST HISTORY:

K/C/O HTN SINCE 4 YEARS AND ON T.LOSARTAN 50MG + HYDROCHLOROTHIAZIDE 12.5 MG N/K/C/O DMII,CVA,CAD,TB,EPILEPSY.

GENERAL EXAMINATION:

 

PATIENT IS CONSCIOUS, COHERENT,COOPERATIVE. MODERATELY BUILT AND NOURISHED

NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS,LYMPHEDENOPATHY,EDEMA VITALS:

TEMP: 98.6F PR: 78BPM

BP: 130/90MMHG RR: 18CPM

CVS: S1S2 HEARD RS: BAE+

P/A: SOFT, NONTENDER CNS EXAMINATION -NFND

PUPILS: NORAML IN SIZE, REACTIVE TO LIGHT TONE RT LT

UL NORMAL NORMAL LL NORMAL NORMAL POWER RT LT

UL 5/5 5/5 LL 5/5 5/5

REFLEXES RT LT BICEPS 2+ 2+

TRICEPS 2+ 2+

SUPINATOR 1+ 1+

KNEE 2+ 2+ ANKLE -- --

PLANTAR FLEXION FLEXION

NECK EXAMINATION:

NECK MOVEMENTS- RESTRICTED NECK STIFFNESS- ABSENT KERNIGS SIGN- NEGATIVE BRUDZINSKI SIGN- NEGATIVE RHOMBERG SIGN- NEGATIVE

FINGER FINGER INCOORDINATION- ANSENT

 

FINGER NOSE COORDINATION- ABSENT SPINE TENDERNESS- ABSENT NYSTAGMUS- ABSENT

EOM MOVEMENTS- NEGATIVE DIPLOPIA- ABSENT

NO RAISED ICT FEATURES

CERVICAL LYMPH NODES - PALPABLE ON LT OCCIPITAL ANGLE NO PALPABLE AXILLARY LYMPH NODES

THYROID SWELLING - PRESENT

GENERAL SURGERY REFFERAL WAS DONE ON 24/8/23 ADVICE :

NO ACTIVE SURGICAL INTERVENTION NEEDED

1. CONTINUE TREATMENT FOR HYPOTHYROIDISM

2. REVIEW AFTER 3 MONTHS IN GS OPD FOR REVIEW ORTHOPAEDICS REFFERAL WAS DONE ON 24/8/23 ADVICE:

DIAGNOSIS:CERVICAL DISC DEGENERATIVE DISEASE WITH MUSCLE SPASM OF NECK MUSCLES

TREATMENT:

TAB.HIFENAC MR BD 1 WEEK TAB. PAN 40MG OD 1 WEEK IFT/TENS APPLICATION

TAB. TRIGABATIN 100MG X 3 WEEKS

ENT REFFERAL DONE ON 24/8/23 I/V/O VERTIGO ADVICE

1.T.VERTIN 8 MG BD TO BE CONTINUED ENDOCRINOLOGY REFFERAL DONE ON 25/8/23 ADVICE:

1. DIABETIC DIET

2. T.THYRONOEM 75MCG

3. T.METFORMIN 500MG PO/BD

Investigation

22/8/23--23/8/23-- 26/8/23

 

TLC

5,300/4.300/ 10,000

HEMOGLOBIN 10.3/11.5/ 12.1 HEMATOCRIT

29.9/34.1/ 36.9

PLATLET 2.05/2.22/ 2.92/ IMPRESSION NCNC ANAEMIA/ NCNC NC NC ANAEMIA / BLOOD PICTURE

RFT

B.UREA 11/10/ 15

S.CREATININE 0.8/0.8/ 0.7 S.NA+ 137/138/ 139 S.K+

4.1/4.2/ 4.2

S.CL- 101/101/ 103 S.CA+2 1.20/1.18/ 1.17

LFT-22/8/23 T.BILURUBIN-0.77 D.BILURUBIN-0.20 AST-94

ALT-92

 

ALP-311 T.PROTEIN-7.2 ALBUMIN-4.1 CUE - 22/8/23 SUGAR- +++ ALBUMIN- NIL PUS CELLS: 3-4 RBC-NIL

CAST-NIL

SEROLOGY(HIV, HBSAG, HCV)-NEGATIVE BLOOD GROUP- B POSITIVE

ESR-40MM/1ST HOUR HB1AC-7.0

T3,T4,TSH-0.98, 8.70,29.51

USG NECK

IMPRESSION- DIFFUSE THYROIDITIS CERVICAL LYMPHADENOPATHY

TIRADS 3 LESION IN RIGHT LOBE OF THYROID

Treatment Given(Enter only Generic Name)

1. INJ.DICLOFENAC IM/SOS

2. INJ. ZOFER 4MG IV/SOS

3. T.PANTOP 40MG PO/OD

4. T.DOLO 650 MG PO/SOS

5. T. NICARDIA 10MG PO/SOS

6. T. LOSARTAN= T. HYDROCHLORTHIAZIDE 50MG/12.5 MG PO/OD

7. T.VERTIN 80MG PO/BD

8. T. THYRONORM 75MCG PO/OD

9. T. METFORMIN 500MG PO/BD

10. INJ.MYORIL (2ML) IM/BD

11. T.PREGABALIN 75MG PO/HS

12. T.CLONAZEPAM 0.25MG PO/HS

 

Advice at Discharge

1. INJ.DICLOFENAC IM/SOS

2. INJ. ZOFER 4MG IV/SOS

3. T.PANTOP 40MG PO/OD

4. T.DOLO 650 MG PO/SOS

5. T. NICARDIA 10MG PO/SOS

6. T. LOSARTAN= T. HYDROCHLORTHIAZIDE 50MG/12.5 MG PO/OD

7. T.VERTIN 80MG PO/BD

8. T. THYRONORM 75MCG PO/OD

9. T. METFORMIN 500MG PO/BD

10. INJ.MYORIL (2ML) IM/BD

11. T.PREGABALIN 75MG PO/HS

12. T.CLONAZEPAM 0.25MG PO/HS

First Encounter: 08/22/2023

• Outcome: mortality.

Case 14

https://himajav.blogspot.com/2024/06/60f-gouty-arthritis-ckd-htn.html

60 year female born and bought up in lower socioeconomic class with two sisters. Milestones achieved normal.She is an illiterate and childhood was pleasant.Patient parents are farmers, she used to engage in daily wage labour work from Childhood. At age 18 she had consanguineous marriage, married to her brother in law. After marriage she has two abortions during her gestations. ?placenta abruptio. Third pregnancy was stillbirth. She had her fourth pregnancy , healthy baby boy was born. She raised and educated her son all by herself.

15 years ago she had pedal edema and decreased urine output, went to RMP and regularly took injections after which her urine output became normal. But once she wasn’t relieved with her symptoms and consulted doctor , found out her right kidney is small/shrunken and was advised for renal transplantation. Because of financial issues she did not undergo transplantation. Two years later she lost her mother due to old age. Three years after her mother Demise she lost her husband in a RTA( Tractor vs Bike). She wasn’t unable to handle the situation and became regular alcoholic. Three years after that she lost her husband her younger sister also met with RTA while coming back from farm and lost her life.

10 years ago she had multiple joint pains which eventually led her to walking with a support. 

7 years ago she married off her son (love marriage) who later had three daughters

3 years ago patient had sudden onset of left upper and lower limb weakness with slurring of speech , took her to local hospital and was diagnosed with CVA and Denovo hypertension 

Intermittently she has recurrent Urinary tract infections , conservatively managed.

1 year ago she had swelling itching and painful toe of left foot, diagnosed as cellulitis and amputation of toe was done.

Since 15 days patient had complains of productive cough, loose stools watery in consistency 5-6 episodes per day. Resolved. Since two days patient has high grade fever associated with chills and rigor associated with burning micturition and shortness of breath grade 4 and was bought to our casualty for further management

DAILY ROUTINE

Usually stays outside home where she can use washroom conveniently, and has a bed setup near the entrance. Since she cannot walk without support she doesn’t walk much and this is her routine 

Wakes up at 6am, freshenup and get her grandchildren ready (from cleaning butts to their dressing)

Has tea at 8am

11am- Have some food usually rice and curry

12pm-2pm she takes nap

2pm- has lunch and takes nap

4pm -she sits in chair and gossips with her hometown friends who visits her home, pass time with her grandchildren and go to bed by 10pm

Her daily routine doesn’t include any physical activity, mostly she spends her day chitchatting and spending time with her grandchildren. She neither watches TV or engage in household chores. 

Summary

Diagnosis

COMMUNITY ACQUIRED PNEUMONIA

- LOBAR CONSOLIDATION IN LEFT LUNG UPPER LOBE

- SEGMENTAL CONSOLIDATION WITH CAVITATION OF RIGHT LUNG LOWER LOBE AKI ON CKD ( STAGE V)

ANEMIA OF CHRNOIC DISEASE

Case History and Clinical Findings

PATIENT CAME WITH COMPLAINTS OF DECREASED URINE OUTPUT SINCE 10 DAYS AND SHORTNESS OF BREATH SINCE 1 DAY.

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS AGO, THEN DEVELOPED DECREASED URINE OUTPUT ASSOCIATED WITH BURNING MICTURITION. COMPLAINTS OF SHORTNESS OF BREATH INSIDIOUS IN ONSET GRADE 4 MMRC, GRADUALLY PROGRESSED. HISTORY OF COUGH SINCE 1 DAY WITH SPUTUM, MUCOID AND HISTORY OF FEVER SINCE 1 WEEK LOW GRADE , CONTINUOUS RELIEVED WITH MEDICATION ASSOCIATED WITH CHILLS AND RIGORS .HISTORY OF LOOSE STOOLS SINCE 15 DAYS 4 TO 5 EPISODES PER DAY WATERY STOOLS, BLOOD IN STOOLS SUBSIDED IN 3 DAYS. HSTORY OF VOMITINGS FOR 5 DAYS 4 EPISODES PER DAY FOOD AS CONTENT SUBSIDED 5 DAYS AGO. HISTORY OF ABDOMINAL PAIN DIFFUSE SINCE 2 MONTHS.HISTORY OF PEDAL EDEMA GRADE II (UPTO LEVEL OF KNEE)

 

PAST HISTORY:

KNOWN CASE OF CKD SINCE 11YEARS ON MEDICAL MANAGEMENT .KNOWN CASE OF HTN SINCE 4 YEARS ON TAB TELMA 40 MG PO/OD

NOT A KNOWN CASE OF DM/CVA/CAD/ASTHMA /EPILEPSY/TB/THYROID DISORDERS PERSONAL HISTORY:

MIXED DIET APPETITE DECREASED.OCCASIONAL ALCOHOLIC 180 ML MONTHLY ONCE SINCE 40 YEARS

ON GENERAL PHYSICAL EXAMINATION-- AT ADMISSION

TEMP:98.6F PR:93 BPM RR:36CPM

BP:100/60mmhg SPO2:95@RA 2L 02 GRBS:173MG/DL

CVS:S1 S2+, NO MURMURS

RS:BAE+, DIFFUSE WHEEZE +, BILATERAL CREPTS IN LSA, IAA ,MA(R >L) DECREASED PER ABDOMEN- SOFT, NON-TENDER

CNS-

PATEINT IS CONSCIOUS, COHERENT AND COOPERATIVE ORIENTED TO TIME , PLACE AND PERSON.

HIGHER MENTAL FUNCTIONS - NORMAL NO FOCAL NEUROLOGICAL DEFICITS REFLEXES : RIGHT LEFT

BICEPS +2 +2

TRICEPS +2 +2

SUPINATOR +1 +1

KNEE +2 +2

ANKLE +1 +1

COURSE IN HOSPITAL:

 

64 YEAR OLD FEMALE, KNOWN HYPERTENSIVE &KNOWN CKD ON REGULAR MEDICATION , CAME WITH COMPLAINTS OF DECREASED URINE OUTPUT SINCE 10 DAYS AND SHORTNESS OF BREATH SINCE 1 DAY.THOROUGH CLINICAL EVALUATION WAS DONE AND NECESSARY INVESTIGATIONS WERE SENT. CHEST X RAY PA VIEW SHOWED CONSOLIDATORY CHANGES IN LEFT LUNG UPPER LOBE AND RIGHT LUNG LOWER LOBE.HRCT WAS DONE ON 5/6/24 SHOWED LOBAR CONSOLIDATION IN LEFT LUNG UPPER LOBE, SEGMENTAL CONSOLIDATION WITH CAVITATION OF RIGHT LUNG LOWER LOBE, SMALL NODULES IN RIGHT LUNG UPPER LOBE .2D ECHO : ON 6/6/24 NO RWMA. MILD LVH + MODERATE TR WITH MILD PAH ,MILD AR, TRIVIAL MR MAC +; SCLEROTIC AV, NO AS/MS IAS- ANEURYSMS/ INTACT, EF= 62 GOOD LV SYSTOLIC FUNCTION GRADE I DIASTOLIC DYSFUNCTION,MINIMAL PE +. USG ABDOMEN DONE ON 05/06/24 SHOWED GRADE III RPD CHANGES IN LEFT KIDNEY WITH LEFT RENAL CORTICAL CYST GRADE II RPD CHANGES IN RIGHT KIDNEY. LAB INVESTIGATIONS SHOWED DERANGED RFT AND HEMOGRAM VALUES (HB-7.6g/dL, TLC- 24000) (RFT -UREA 153 mg/dl, CREATININE 4.5 mg/dl AND BLOOD LACTATE -

17.2 ABG SHOWED METABOLIC ACIDOSIS-PH 7.20,PCO2 15.9 ,PO2 76.6 ,HCO3 6.1 ,St.HCO3 9.4). PATIENT WAS PROVISIONALLY DIAGNOSED AS COMMUNITY ACQUIRED PNEUMONIA(LOBAR CONSOLIDATION IN LEFT LUNG UPPER LOBE, SEGMENTAL CONSOLIDATION WITH CAVITATION OF RIGHT LUNG LOWER LOBE, AKI ON CKD ( STAGE V), ANEMIA OF CHRNOIC DISEASE. ON ADMISSION URINE OUTPUT WAS 300ML. CPAP SUPPORT WAS INITIATED. PATIENT WAS STARTED ON ANTIBIOTICS (INJ. PIPTAZ 2.25 g IV TID, INJ. LEVOFLOXACIN 750 mg IV OD), ANTIVIRALS (TAB FLUVIR 75 MG PO/BD) DIURETICS (INJ LASIX 40 MG IV/TID).NEPHROLOGY OPINION WAS TAKEN AND ADVISE FOLLOWED. SODIUM BICARB (150 MEQ IN 200 ML NS) WAS GIVEN. OPTHAL OPINION TAKEN ON 5/06/24 AND THEY ADVISED FOR CATARACT SURGERY AND DILATED FUNDUS EXAMINATION AFTER PATIENT IS STABILISED. URINE CULTURE SHOWED INSIGNIFICANT GROWTH,WET MOUNT -NO PUS CELLS SEEN. BLOOD CULTURE(FIRST SUB CULTURE) SHOWED SKIN COMMENSALS (MICROCOCCI GROWTH). ON DAY 2-I/O (INPUT/OUTPUT) WAS 1

700 /1150 ML. ON DAY 3 I/O WAS 2850/800 ML. PATIENT RFT DID NOT IMPROVE WITH CREATININE VALUES OF [4.5(5/6/24)- 4.4(6/6/24)-5.1(7/6/24)- 5.5(8/6/24)]. AND SERIAL ABG SHOWS NO IMPROVEMENT IN METABOLIC ACIDOSIS, BICARB LEVELS AND DECREASED URINE OUTPUT. NEPHROLOGY REVIEW WAS TAKEN AND NEED FOR HEMODIALYSIS WAS ADVISED. DURING THE COURSE PATIENT WAS TREATED WITH IV FLUIDS, CORTICOSTEROIDS, ANTIBIOTCS, PPIs, ANTIPYRETICS, ANTIVIRALS, DIURETICS, ANTIEMETICS, MULTIVITAMINS AND OTHER SUPPORTIVE DRUGS. PATIENT WAS COUNSELLED FOR HEMODIALYSIS AND NECESSARY CONSENTS WERE TAKEN. PATIENT WAS GRADUALLY IMPROVED CLINICALLY, AND IS HENCE BEING DISCHARGED AFTER STABILISATION.

 

Investigation HAEMOGRAM HB-7.6g/dL

N/L/E/M/B -94/04/00/02/00 PCV-22.2

TLC-13,400 RBC-2.68

PLt: 1.5LAKHS MCV-82.8

MCH-28.3SMEAR :NORMOCYTIC NORMOCHROMIC

ABG 05-06-2024 03:30:PMPH 7.20PCO2 15.9PO2 76.6HCO3 6.1St.HCO3 9.4BEB -20.6BEecf - 20.7TCO2 13.1O2 Sat 94.1O2 Count 13.6

RFT 05-06-2024 04:22:PMUREA 153 mg/dl 42-12 mg/dlCREATININE 4.5 mg/dl 1.1-0.6 mg/dlURIC

ACID 9.1 mmol/L 6-2.6 mmol/LCALCIUM 9.8 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.5 mg/dl 4.5-2.5

mg/dlSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.3 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

104 mmol/L 98-107 mmol/LHBsAg-RAPID 05-06-2024 04:22:PM Negative Anti HCV Antibodies - RAPID 05-06-2024 04:22:PM Non Reactive

LIVER FUNCTION TEST (LFT) 05-06-2024 04:26:PMTotal Bilurubin 0.96 mg/dl 1-0 mg/dlDirect Bilurubin 0.20 mg/dl 0.2-0.0 mg/dlSGOT(AST) 15 IU/L 31-0 IU/LSGPT(ALT) 11 IU/L 34-0

IU/LALKALINE PHOSPHATASE 139 IU/L 141-53 IU/LTOTAL PROTEINS 4.6 gm/dl 8.3-6.4

gm/dlALBUMIN 2.39 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.08

COMPLETE URINE EXAMINATION (CUE) 05-06-2024 05:55:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

RFT 06-06-2024 05:27:AMUREA 172 mg/dl 42-12 mg/dlCREATININE 4.4 mg/dl 1.1-0.6 mg/dlURIC

ACID 8.7 mmol/L 6-2.6 mmol/LCALCIUM 8.9 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 6.1 mg/dl 4.5-2.5

mg/dlSODIUM 140 mmol/L 145-136 mmol/LPOTASSIUM 3.9 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

103 mmol/L 98-107 mmol/L

ABG 06-06-2024 05:27:AMPH 7.15PCO2 19.5PO2 77.4HCO3 6.6St.HCO3 9.2BEB -20.7BEecf - 20.6TCO2 14.8O2 Sat 93.6O2 Count 11.7

ABG 06-06-2024 06:05:AMPH 7.10PCO2 23.5PO2 50.1HCO3 7.0St.HCO3 8.8BEB -21.0BEecf - 20.7TCO2 16.0O2 Sat 81.7O2 Count 9.9

ABG 07-06-2024 12:29:AMPH 7.10PCO2 21.3PO2 97.3HCO3 6.5St.HCO3 8.1BEB -21.3BEecf - 21.3TCO2 15.4O2 Sat 93.3O2 Count 5.7

 

RFT 07-06-2024 12:29:AMUREA 182 mg/dl 42-12 mg/dlCREATININE 5.1 mg/dl 1.1-0.6 mg/dlURIC

ACID 8.6 mmol/L 6-2.6 mmol/LCALCIUM 8.7 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 6.0 mg/dl 4.5-2.5

mg/dlSODIUM 140 mmol/L 145-136 mmol/LPOTASSIUM 3.7 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

106 mmol/L 98-107 mmol/L

ABG 07-06-2024 09:37:AMPH 7.18PCO2 17.6PO2 86.3HCO3 6.3St.HCO3 9.3BEB -20.7BEecf - 20.7TCO2 14.0O2 Sat 95.3O2 Count 12.4

RFT 08-06-2024 05:07:AMUREA 161 mg/dl 42-12 mg/dlCREATININE 5.5 mg/dl 1.1-0.6 mg/dlURIC

ACID 8.4 mmol/L 6-2.6 mmol/LCALCIUM 9.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 8.5 mg/dl 4.5-2.5

mg/dlSODIUM 145 mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

106 mmol/L 98-107 mmol/L

USG ON 05/06/24 IMPRESSION :-

GRADE III RPD CHANGES IN LEFT KIDNEY WITH LEFT RENAL CORTICAL CYST GRADE II RPD CHANGES IN RIGHT KIDNEY

2D ECHO : ON 6/6/24 TACHYCARDIA DURING STADY NO RWMA. MILD LVH +

MODERATE TR WITH MILD PAH (RVSP = 45+10= 55 mm Hg) MILD AR ( AR-PHT- 527 ml/sec ); TRIVIAL MR

MAC +; SCLEROTIC AV, NO AS/MS IAS- ANEURYSMS/ INTACT

EF= 62 GOOD LV SYSTOLIC FUNCTION GRADE I DIASTOLIC DYSFUNCTION MINIMAL PE +

IVC SIZE (1.18 CMS ) COLLAPSING

HRCT WAS DONE ON 5/6/24

IMPRESSION- LOBAR CONSOLIDATION IN LEFT LUNG UPPER LOBE, SEGMENTAL CONSOLIDATION WITH CAVITATION OF RIGHT LUNG LOWER LOBE, SMALL NODULES IN RIGHT LUNG UPPER LOBE .

Treatment Given(Enter only Generic Name)

1. CONTINUOUS CPAP

 

2. IVF NS @100 ml (U/O +50 ml/hr)

3. INJ. PIPTAZ 2.25 g IV TID X 4DAYS

4. INJ. LEVOFLOXACIN 750 mg IV OD X4 DAYS

5. TAB. FLUVIR 75 mg PO/BD X 3DAYS

6. INJ. PAN 40 mg IV OD

7. TAB LASIX 40 mg PO/OD

8. INJ. ZOFER 4 mg IV BD

9. INJ. OPTINEURON 1 amp IN 100 ml NS IV OD

10. INJ. NEOMOL 1g IV SOS IF TEMP >100F

11. INJ. EPO 4000 IU S/C WEEKLY TWICE

12. TAB SHELCAL CT 500 mg PO/OD

13. TAB. PCM 650 mg PO SOS

14 TAB. NODOSIS 500 mg PO/OD

15. TAB. OROFER XT PO/OD 1-0-0

16. NEB. DUOLIN 6TH HOURLY BUDECORT 6TH HOURLY Advice at Discharge

1. CONTINUOUS CPAP

2. IVF NS @100 ml (U/O +50 ml/hr)

3. INJ. PIPTAZ 2.25 g IV TID X 3DAYS

4. INJ. LEVOFLOXACIN 750 mg IV OD X3 DAYS

5. TAB. FLUVIR 75 mg PO/BD X 2DAYS

6. INJ. PAN 40 mg IV OD

7. TAB LASIX 40 mg PO/OD

8. INJ. ZOFER 4 mg IV BD

9. INJ. OPTINEURON 1 amp IN 100 ml NS IV OD

10. INJ. NEOMOL 1g IV SOS IF TEMP >100F

11. INJ. EPO 4000 IU S/C WEEKLY TWICE

12. TAB SHELCAL CT 500 mg PO/OD

13. TAB. PCM 650 mg PO SOS

14 TAB. NODOSIS 500 mg PO/OD

15. TAB. OROFER XT PO/OD 1-0-0

16. NEB. DUOLIN 6TH HOURLY BUDECORT 6TH HOURLY

First Encounter: 06/05/2024

• Outcome:

Case 15

https://himajav.blogspot.com/2024/06/48f-mnd-htn-dm-cva.html

Case 15

48 year female born and bought up in thopicherla to a family of 6 members including four siblings , mother and father. achieved normal milestones. Childhood was pleasant. Father used to do pottery. When I asked how much is the income of her father and that people only buy mud pots only during summer, how would family earn money in other seasons- patient answered that summer is a great business deal for us, but there are many other occasions like temple room,weddings, funerals etc where people use mud pots . 

Her teacher is a male and alcoholic who used to beat kids, in fear of that she stopped going to school.

At age 9 patient had pain abdomen which was diagnosed as appendicitis and underwent appendectomy 

She lost her father 15 years ago due to old age. Mother is now older than 100 years bedridden stays at her elder sister home

Later she lost her elder brother due to cancer at Osmania General hospital

At age 18 patient attained menarche, in the same year she was married and moved to miryalgauda and started working as a maid in houses. She had one girl child after marriage. 10 years ago she lost her husband due to heavy alcohol consumption. Since then she raised the kid all by herself. When her kids age was 9 she was unable to grasp and learn languages like English and Hindi for which her teachers used to beat her up. Seeing the scars she felt low and discontinued the studies and married her off to an auto driver who later had two  children(girls)

10 years ago she had giddiness, went to local hospital and was diagnosed with hypertension

6 years ago her daughter gave birth to a girl child, while she was taking care of the child she had sudden onset of giddiness and had a fall, got hurt on her head by knocking onto foot of bed, as she was bleeding her daughter called out for neighbors for help, one woman came and applied tea powder to stop the bleeding. Later she was taken to hospital and had four sutures at the site. One week later as patient wound healing was delayed she went for a follow up and diagnosed with Diabetes. She was advised to cut her hair for fast wound healing, as hairs can cause sweat and therefore delay the healing. Since then she had complains of neck pain

4 years ago while patient was talking to a lady on road, she suddenly pushed her onto the road which made her land up in hospital with fracture to her right lower limb. She had fast recovery and used support of a walker for a while and later walked normally on her own.

One year ago in March 2023 patient had sudden onset of deviation of mouth, went to hospital, CT head was done and counselled that patient had blood clot in the brain. Was admitted for 10 days in neuro hospital, during the stay her BP was 200 and sugars were 600. All her parameters were corrected and patient was discharged 

6 months after the discharge patient had sudden onset of tremors in left hand followed by left hand weakness, one week later she had weakness of left lower limb, one week later she experienced similar complains in right upper and lower limbs. 

DIET- MIXED

BOWEL AND BLADDER- REGULAR

ADDICTIONS- occasional toddy drinker 

DAILY ROUTINE

BEFORE ILLNESS

wakes up at 6am, freshen up , cleans home and used to go for work by 7am

Works in three houses till 12pm -cleans and sweeps floor, wash utensils, lunch provided and come back to her home by 12pm

Returns home, wash clothes, dry them and Have lunch and takes nap till 4pm

At 5pm she again go for work and returns home by 7pm

At 9pm she goes to bed - no sleep disturbances

AFTER ILLNESS

All her routine was changed, and had to depend on someone even to go for washroom which made her more anxious. She often has insomnia and spends time mostly on bed.

VITALS

TEMP-97.8F

PR- 80bpm

RR- 23cpm

BP-130/80mmhg

SPO2-98% at RA

GRBS- 123mg/dl

EXAMINATION

CNS

TONE - NORMAL IN ALL FOUR LIMBS

POWER- RIGHT       LEFT

UL           4/5              4/5

LL           3/5                3/5

UPPER LIMB REFLEXES - NORMAL

LOWERLIMB DEEP TENDON REFLEXES - EXAGGERATED 

SENSORY- INTACT

CVS-S1S2 NO MUMRMUR

RS- BAE NVBS

PA - SOFT NT

PROVISIONAL DIAGNOSIS

MOTOR NEURON DISEASE

Known case of HTN DM CVA

Summary 

Diagnosis

?MND

?CERVICAL COMPRESSIVE MYELOPATHY K/C/O HTN AND DM 2 SINCE 6 YEARS

Case History and Clinical Findings

CHIEF COMPLAINTS :

COMPLAINTS OF WEAKNESS OF B/L UPPER LIMBS AND LOWER LIMBS SINCE 6 MONTHS. HISTORY OF PRESENT ILLNESS:

PATIENT WAS APPARENTLY ALRIGHT 1.5 YEARS BACK THEN SHE HAD HISTORY OF CVA DUE TO INFARCT IN CEREBELLUM WITH HISTORY OF DEVIATION OF MOUTH . NOW SHE IS HAVING WEAKNESS OF LEFT UPPER LIMB AND LOWER LIMB (WRIST-FOREARM-ARM- TRUNK-THIGH-LEG-FOOT) TO RIGHT UL AND LOWER LIMB ((WRIST-FOREARM-ARM-TRUNK- THIGH-LEG-FOOT) MORE RECENT.

NO H/O INVOLUNTARY MOVEMENTS

NO H/O GIDDINESS , SOB, ORTHOPNEA , PND NO H/O ABDOMINAL PAIN

NO H/O VOMITING , DIARRHEA

NO H/O BOWEL AND BLADDER ABNORMALITY PAST HISTORY :

K/C/O DM SINCE 6 YEARS

K/C/O HTN SINCE 6 YAERS ON MEDICATION.

 

PERSONAL HISTORY :

DIET - MIXED APPETITE - NORMAL SLEEP - ADEQUATE

BOWEL& BLADDER MOVEMENTS - REGULAR ADDICTIONS - ALCOHOL :OCCASIONAL.

GENERAL PHYSICAL EXAMINATION :

PATIENT IS CONSCIOUS , COHERENT &COOPERATIVE , WELL ORIENTED TO TIME AND PLACE .

NO PALLOR/ ICTERUS / CYANOSIS / CLUBBING / LYMPHADENOPATHY / OEDEMA. VITALS :

BP ; 160/100MM HG PR : 78 BPM

RR : 22 CPM TEMP ; 98F SPO2 : 98 @ RA

GEBS- 196 MG/ DL

SYSTEMIC EXAMINATION :

CNS : SENSORY SYSTEM SPINOTHALAMIC RT LT

CRUDE TOUCH N DECREASED

POSTERIOR COLUMN

FINE TOUCH N DECREASED VIBRATION

ACROMION N DECREASED OLECRENON N DECREASED STYLOID N DECREASED

TIBIAL TUBEROSITY N DECREASED SHAFT OF TIBIAL N DECREASED MEDIAL MALLEOLUS N DECREASED

 

GREAT TOE N DECREASED

CORTICAL

TWO POINT DISCRIMINATION TACTILE LOCALISATION GRAPHESTHESIA N ABSENT STERIOGNOSIS N NORMAL

RT LT

POWER: UL DECREASED DECREASED LL DECREASED DECREASED

UL DECREASED DECREASED LL DECREASED DECREASED

BULK: UL DECREASED DECREASED LL DECREASED DECREASED REFLEXES :

B T S K A

R +3 +3 + 1 +3 +

L +3 +3 +1 +3 +

MUSCULOSKELETAL SYSTEM: THENAR ATROPHY

CVS :

S1, S2 HEARD , NO MURMURS

RS :

BAE + , NVBS

P/A :

SOFT , NON TENDER

 

COURSE IN THE HOSPITAL : A 48 YR OLD FEMALE PATIENT CAME WITH COMPLAINTS OF WEAKNESS OF B/L UPPER LIMBS AND LOWER LIMBS SINCE 6 MONTHS AND HAS H/O CVA 1 AND HALF YR AGO [ DEVIATION PF MOUTH WITH CT BRAI -? INFARCT] WITH COMORBIDITIES OF DM,HTN WHICJH ARE CONTROLED WELL AND UNDERE ORAL MEDICATION ANTI DM AND ANTI HTN MEDICATIONS .CNS EXAMINATION WAS DONE AND DIFFERENTIALS OF MND AND CERVICAL COMPRESSION MYELOPATHY WERE CONSIDERED.MRI SPINE REVEALED MILD CENTRAL CANAL STENOSIS . NEUROPHYSICIAN OPINION WAS TAKEN AND OPINIONED A DIAGNOSIOS OF POST STRI=OKE MND AS PT HAS BOTH UMN& LMN FETAURES AT SAM LEVEL AND ADVISED FOR NERVE CONDUCTION STUDIES AND MRI BR5AIN FOR WHICH THEY WERE NOT WILLING .SO THEY ARE BEING DISCHARGED UNDER ADVICE OF NEUROPHYSICIAN FOLLOW UP WITH NERVE CONDUCTION STUDIES AND MRI BRAIN REPORTS TREATED WITH 1)INJ OPTINEURIN 1 AMP IN 100ML NS IV/OD 2)INJ TRAMADOL 1 AMP IN 100ML NS IV/OD 3)TAB TRIGABANTIN 10 MG PO/HS/9PM 4)TAB TELMA 40 MG PO/OD 5)TAB METFORMIN 500MG + GLIMEPERIDE 1MG PO/OD .PATIENT IS BEING DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION, UNDER LOW DOSE STEROID AND PHYSIOTHERAPY

Investigation

Name Value Range

Name Value RangeCOMPLETE URINE EXAMINATION (CUE) 10-06-2024 03:51:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 4-5EPITHELIAL CELLS 2-4RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

HBsAg-RAPID 10-06-2024 03:51:PM NegativeAnti HCV Antibodies - RAPID 10-06-2024 03:51:PM

Non Reactive

POST LUNCH BLOOD SUGAR 10-06-2024 03:52:PM 213 mg/dl 140-0 mg/dlBLOOD UREA 10-06-

2024 03:52:PM 14 mg/dl 42-12 mg/dl

SERUM CREATININE 10-06-2024 03:52:PM 0.7 mg/dl 1.1-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) 10-06-2024 03:52:PMSODIUM 139 mmol/L 145-136 mmol/LPOTASSIUM 3.9 mmol/L 5.1-3.5

mmol/LCHLORIDE 103 mmol/L 98-107 mmol/L

 

LIVER FUNCTION TEST (LFT) 10-06-2024 03:52:PMTotal Bilurubin 0.88 mg/dl 1-0 mg/dlDirect Bilurubin 0.19 mg/dl 0.2-0.0 mg/dlSGOT(AST) 27 IU/L 31-0 IU/LSGPT(ALT) 22 IU/L 34-0

IU/LALKALINE PHOSPHATASE 144 IU/L 98-42 IU/LTOTAL PROTEINS 6.8 gm/dl 8.3-6.4

gm/dlALBUMIN 4.15 gm/dl 5.2-3.5 gm/dlA/G RATIO 1.57NameValueRangeNameValueRangeCOMPLETE URINE EXAMINATION (CUE) 10-06-2024 03:51:PM COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINNilSUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS4-5EPITHELIAL CELLS2-4RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilHBsAg-RAPID10-

06-2024 03:51:PMNegative Anti HCV Antibodies - RAPID10-06-2024 03:51:PMNon Reactive POST LUNCH BLOOD SUGAR10-06-2024 03:52:PM213 mg/dl140-0 mg/dlBLOOD UREA10-06-2024 03:52:PM14 mg/dl42-12 mg/dlSERUM CREATININE10-06-2024 03:52:PM0.7 mg/dl1.1-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) 10-06-2024 03:52:PM SODIUM139 mmol/L145-136

mmol/LPOTASSIUM3.9 mmol/L5.1-3.5 mmol/LCHLORIDE103 mmol/L98-107 mmol/LLIVER FUNCTION TEST (LFT) 10-06-2024 03:52:PM Total Bilurubin0.88 mg/dl1-0 mg/dlDirect Bilurubin0.19 mg/dl0.2-0.0 mg/dlSGOT(AST)27 IU/L31-0 IU/LSGPT(ALT)22 IU/L34-0 IU/LALKALINE PHOSPHATASE144 IU/L98-42 IU/LTOTAL PROTEINS6.8 gm/dl8.3-6.4 gm/dlALBUMIN4.15

gm/dl5.2-3.5 gm/dlA/G RATIO1.57 HEMOGRAM:

HB - 14.8 GM/DL

TLC - 11000 CELLS / CUMM N/L/E/M/B = 53/39/2/6/0 % PCV - 39.9 VOL %

MCV - 65.1 FL MCH - 31.1 PG MCHC - 36.1 %

RBC - 4.6 MILLION/ CU MM PLATELET - 3.3 LAKHS / CU MM

SMEAR : NORMOCYTIC NORMOCHROMIC FBS :131 MG/DL

PLBS : 213 MG /DL HBA1C: 7%

MRI CERVICAL SPINE WITH WHOLE SPINE SCREENING :

C5 C6 DISC OSTEOPHYTE COMPLEX CAUSING MILD CENTRAL CANAL STENOSIS

Treatment Given(Enter only Generic Name)

1) INJ OPTINEURIN 1 AMP IN 100ML NS IV/OD

2) INJ TRAMADOL 1 AMP IN 100ML NS IV/OD

3) TAB TRIGABANTIN 10 MG PO/HS/9PM

4) TAB TELMA 40 MG PO/OD

5) TAB METFORMIN 500MG + GLIMEPERIDE 1MG PO/OD

Advice at Discharge

TAB.TRIGABANTIN 10 MG PO/HS

TAB.TELMA 40 MG PO/OD 1-0-0 TO BE CONTINUED TAB GLIMI - M1 PO/OD 1-0-0 TO BE CONTINUED TAB.DEFLOZOCORT 6 MG PO/OD 1-0-0 @ 10 AM

TAB.METFORMIN 300 MG PO/OD 0-0-1 @ 10 PM TO BE CONTINUED

REVIEW TO GM OPD WITH NERVE CONDUCTION STUDIES AND MRI BRAIN - PLAIN NEED EVALUATION BY NEURO PHYSICIAN

First Encounter: 06/10/2024

• Outcome:

Case 16

https://himajav.blogspot.com/2024/06/74m-chf-htn-dm-prostate-ca.html

Case 16

74 male from jalalpuram came with complaints of sob and chest pain since 3 days 

Patient was born and brought up in jalalpuram,lived along with parents and 3 siblings,studies till 9th standard,no health issues in childhood, discontinued education and entered carpenter work at 16 yrs of age.

He got married at age of 21 years and had 3 sons and 1 daughter and lead a relatively healthy life,

Patient remained asymptomatic till 14 years ago then he developed tingling sensation and weakness of limbs intermittently for which he went to local hospital and was diagnosed of having high blood pressures around 200/100 and was started on anti hypertensives,he was continuing medication and his bp was under control and remained asymptomatics until 7 yrs ago,

At that time he had h/o burning micturition along with pain and dribbling of urine ,he went to local hospital for that and was diagnosed of having prostatic carcinoma and resection of tumor was done at that time and also used medication for 2 years,in between he went to warangal as he was unsatisfied with the treatment of doctors there and went to warangal for further treatment as the symptoms like polyuria,burning micturition persisted even after surgery,there he was found to have recurrence of prostatic carcinoma and placed him on medical management,

Since then he was on medication for carcinoma and hypertension,

2 months ago patient developed weakness of limbs for which he went to hospital and found to have high blood sugars and was started on oral hypoglycemics,during that time he had itching over limbs and accidentally ruptured a nodule on his leg and undervent surgical procedure to close that wound

And discharged after 7 days.Since then he was worried about his health and as his financial conditions becoming worse he felt some what tensed and depressed and stopped taking medications for prostatic cancer,

Since 1 month patient noticed that he is having sob and intermittent chest pain while doing sternous work and while lifiting weights,

Sob and chest pain aggrevated since past 3-4 days for which he was brought to casuality by his attenders

No addictions

No significant family history

Summary

Diagnosis

1)HEART FAILURE SECONDARY TO CAD/CAD AKINETIC RCA,LCX HYPOKINETIC WITH REDUCED EF (32%) 2)ATRIAL FIBRILLATION

3) K/C/O HTN SINCE 5 YEARS ; K/C/O DM2 SINCE 5 MONTHS

4) S/P B/L ORCHIODECTOMY SECONDARY TO CASTRATION RESISTENT PROSTATE CARCINOMA 5 YEARS AGO

Case History and Clinical Findings

CHIEF COMPLAINTS:

SHORTNESS OF BREATH SINCE 1 WEEK CHEST PAIN SINCE 1 WEEK

HISTORY OF PRESENT ILLNESS:

PATIENT WAS APPARENTLY AASYMPTOMATIC 1 WEEK BACK THEN HE DEVELOPED DIFFICULTY IN BREATHEING SINCE 1 WEEK ASSOCIATEWD WITH ORTHOPNEA PND SWEATING GIDDINESS .

PATIENT COMPLAINTS OF CHEST TIGHTNESS CHEST PAIN PATIENT HAS NO H/O INVOLUNTARY MOVEMENTS

NO H/O ABDOMINAL PAIN

H/O NOCTURIA 5-6 TIMES AT NIGHT PAST HISTORY:

K/C/O DM SINCE 3 MONTHS

 

K/C/F HTN SINCE 5 YEARS

PERSONAL HISTORY :

DIET - MIED APPETITE - NORMAL SLEEP - ADEQUATE

BOWEL& BLADDER MOVEMENTS - REGULAR AND NOCTURIA ADDICTIONS - NIL

GENERAL PHYSICAL EXAMINATION :

PATIENT IS CONSCIOUS , COHERENT &COOPERATIVE , WELL ORIENTED TO TIME AND PLACE .

NO PALLOR/ ICTERUS / CYANOSIS / CLUBBING / LYMPHADENOPATHY / OEDEMA. VITALS :

BP ; 140/70MM HG PR : 84 BPM

RR : 20CPM TEMP ; 98F SPO2 : 94 @ RA

GEBS- 137 MG/ DL

SYSTEMIC EXAMINATION :

CNS :NFND REFLEXES B T S K A

R +2 +2 + 1 +2 +1

L +2 +2 +1 +2 +1

CVS :

S1, S2 HEARD , NO MURMURS

RS :

 

BAE + , NVBS

ADVENTITIOUS SOUNDS : CREPTS PRESENT

P/A :

SOFT , NON TENDER

COURSE IN THE HOSPITAL :

74Y OLD MALE CAME TO CASUALITY WITH C/O SHORTNESS OF BREATH SINCE 1 WEEK

.CHEST PAIN SINCE 1 WEEK .ALL NECESSARY INVESTIGATIONS WERE SENT .PATIENT WAS DIAGNOSED TO1)HEART FAILURE SECONDARY TO CAD/CAD AKINETIC ,RCA,LCX HYPOKINETIC WITH REDUCED EF (32%) 2)ARTERIAL FIBRILLATION 3)K/C/O HTN SINCE 5 YEARS ; K/C/O DM2 SINCE 5 MONTHS 4)S/P B/L ORCHIODECTOMY SECONDARY TO CASTRATION RESISTENT PROSTATE CARCINOMA 5 YEARS AGO. K/C/O DM SINCE 3 MONTHS .PATIENT WAS TREATED CONSERVATIVELY WITH TAB.ECOSPRIN,TAB.DABIGATRAN,TAB.DIGOXIN,TAB.VYMADA,TAB.GLIMI-M1,SYP POTKLOR,SYP.CREMAFFIN PLUS AND INJ AUGMENTIN AND INJ.METROGYL AND TAB MET- XL AND ACCORDINGLY .PATIENT IS BEING DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION .

Investigation

Name Value Range

Name Value RangePOST LUNCH BLOOD SUGAR 10-06-2024 10:46:AM 138 mg/dl 140-0 mg/dl RFT 10-06-2024 10:46:AMUREA 24 mg/dl 50-17 mg/dlCREATININE 0.8 mg/dl 1.3-0.8 mg/dlURIC

ACID 2.0 mmol/L 7.2-3.5 mmol/LCALCIUM 10.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.4 mg/dl 4.5-

2.5 mg/dlSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.4 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 99 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 10-06-2024 10:46:AMTotal Bilurubin 2.90 mg/dl 1-0 mg/dlDirect Bilurubin 0.58 mg/dl 0.2-0.0 mg/dlSGOT(AST) 38 IU/L 35-0 IU/LSGPT(ALT) 35 IU/L 45-0 IU/LALKALINE PHOSPHATASE 103 IU/L 119-56 IU/LTOTAL PROTEINS 6.4 gm/dl 8.3-6.4 gm/dlALBUMIN 4.1 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.82

COMPLETE URINE EXAMINATION (CUE) 10-06-2024 10:46:AMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilHBsAg-RAPID 10-06-

2024 10:46:AM Negative

Anti HCV Antibodies - RAPID 10-06-2024 10:46:AM Non ReactiveSERUM ELECTROLYTES (Na, K, C l) 11-06-2024 05:21:AMSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.3 mmol/L 5.1-3.5

mmol/LCHLORIDE 98 mmol/L 98-107 mmol/L

 

SERUM ELECTROLYTES (Na, K, C l) 11-06-2024 10:37:PMSODIUM 140 mmol/L 145-136

mmol/LPOTASSIUM 3.0 mmol/L 5.1-3.5 mmol/LCHLORIDE 98 mmol/L 98-107 mmol/LRFT 12-06-

2024 10:46:PMUREA 45 mg/dl 50-17 mg/dlCREATININE 0.9 mg/dl 1.3-0.8 mg/dlURIC ACID 3.9

mmol/L 7.2-3.5 mmol/LCALCIUM 9.8 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.0 mg/dl 4.5-2.5

mg/dlSODIUM 137 mmol/L 145-136 mmol/LPOTASSIUM 3.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 99

mmol/L 98-107 mmol/L

Treatment Given(Enter only Generic Name)

1. FLUID RESTRICTION <1.5L/DAY

2. SALT RESTRICTION <2.5 GM/DL

3. INJ.LASIX 100MG IN 50 ML NS @5ML./HR

4. INJ.LASIX 40MG IV/OD

5. INJ.HAI S/C TID

6. TAB.TELMISARTAN 40MG PO/OD

7. TAB.MET-XL 25MG PO/OD

8. TAB.ECOSPRIN GOLD (75/75/20) PO/HS

9. TAB.ABIRATERONE 500MG PO/OD

10. TAB.VYMADA 50MG PO/OD

11. SYP CREMAFFIN PLUS 15ML PO/STAT

12. TAB.WYSOLONE 5MG PO/OD

15. TAB.DIGOXIN 0.25 MG PO/OD

16. TAB.DABIGATRAN 110MG PO/BD

17. TAB.GLIMI -M1 PO/BD

18. SYP POTKLOR 15ML IN 100 ML WATER PO/TID

19. ZENFLOX - OZ PO/BD

Advice at Discharge

1.FLUID RESTRICTION <1.5L/DAY2.SALT RESTRICTION <2.5 GM/DL3.TAB . GLIMI M1 PO/OD6.TAB.TELMISARTAN 40MG PO/OD7.TAB.MET-XL 25MG PO/OD8.TAB.ECOSPRIN GOLD (75/75/20) PO/HS9.TAB.VYMADA 50MG PO/OD10.SYP CREMAFFIN PLUS 15ML PO/STAT11.TAB.WYSOLONE 5MG PO/OD14.TAB.DIGOXIN 0.25 MG PO/OD15.TAB.DABIGATRAN 110MG PO/BD16.SYP POTKLOR 15ML IN 100 ML WATER PO/TID X5 DAYS17. TAB ZENFLOX - OZ PO/BD X 5 DAYS

First Encounter: 06/10/2024

• Outcome: