202313738
Case History and Clinical Findings
SUDDEN UNRESPOSIVNESS SINCE 6PM ON 27/03/23
HISTORY OF PRSESNTING ILLNESS
PATIENT
WAS APPARENTLY ASYMPTOMATIC 10 YEARS BACK THEN DEVELOPED GIDDINESS FOR WHICH HE WENT TO LOCAL HOSPITAL
AN D WAS DIAGNOSED AS HAVING
DIABETES AND HYPERTENSION ON MEDICATION SINCE THEN
HISTORY OF
WEAKNESS OF LEFT UL AND LL 3 YEARS AGO DIAGNOSED AS CVA
15
DAYS AGO DEVELOPED COUGH WITH EXPECTORATION WHITE IN COLOR AND BILATERAL LOWER
LIMB SWELLING INSIDIOUS ONSET GRADUALLY PROGRESSIVE AND FEVER LOW GRADE ON AND
OFF SINCE 15 DAYS AND DEVELOPED SHORTNESS OF BREATH EVEN AT REST FOR WHICH HE
WENT TO LOCAL HOSPITAL AND GOT AND TREATED WITH ANTIBIOTICS FOR 6 DAYS AND GOT DISCHARGED ON LAMA AND PATIENT
SYMPTOMATICALLY IMPROVED AND SINCE EVENING 6 PM DEVELOPED SUDDEN ONSET UNRESPOSIVNESS
PAST HISTORY
: KNOWN CASE OF TYPE 2 DM AND ON TAB GLIMI
M2 2MG/500MG AND HYPERTENSION
SINCE 10 YEARS AND ON T MET-XL 25mg/PO/OD
K/C/O CVA3 YRS AGO AND ON TAB ECOSPIRIN AV K/C/O CAD
PERSONAL HISTORY DIET MIXED APPETITE NORMAL
BOWEL AND BLADDER REGULAR SLEEP ADEQUATE
FAMILY HISTORY
NOT RELEVANT GERNERAL
EXAMINATION
O/E: PATIENT IS
CONSCIOUS AND COHERENT
NO SIGNS
OF PALLOR, ICTERUS,
CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA VITALS
TEMP:98.6F PR:74 BPM RR:18
CPM
BP:130/80 MM HG
GRBS - 33MG/DL
AT PRESENTATION ,142MG/DL AFTER 25% DEXTROSE
BOLUS GCS - E2V1M5 AT PRESENTATION
CVS: S1 S2 HEARD
, NO MURMURS
RS: BAE PRESENT , NO ADDED
SOUNDS P/A: SOFT, NON TENDER
CNS: PATIENT IS ORIENTED TO TIME PLACE
AND PERSON GCS E2V1M5
NO NECK STIFFNESS NO KERNINGS SIGN
TONE RIGHT UL
AND LL INCREASED
LEFT UL AND LL INCREASED POWER RIGHT UL AND LL 5/5
LEFT UL AND LL 4/5 REFLEXES
BICEPS RIGHT AND LEFT POSITIVE TRICEPS RIGHT AND LEFT POSITIVE
SUPINATOR RIGHT AND LEFT NEGATIVE KNEE RIGHT AND LEFT POSITIVE ANKLE RIGHT AND LEFT POSITIVE
PLANTAR RIGHT
AND LEFT EXTENSOR RESPONSE
Investigation 27-03-23
HEMOGRAM HB 10.4
TLC 7800
PLATELET COUNT 1.71
PCV 31.2
RBC 3.65
30-3-23
HB 11.1
TLC 6200
PLATELET COUNT 1.56
PCV 33
RBC 3.82
31-3-23
HB 12.6
TLC 5900
PCV 37.4
RBC 4.33
PLATELET COUNT 2.02
1-4-23
HB 10.9
TLC 5400
PCV 33.4
RBC 3.84
PLATELET COUNT 1.99
2-4-23
HB 10.2
TLC 4900
PCV 30.9
RBC 3.55
PLATELET COUNT 1.9
2D ECHO
AORTIC VALVE CALCIFIED,THICKENED RIGHT ATRIUM DILATED
RIGHT VENTRICLE
DILATED LEFT ATRIUM DILATED
LEFT VENTRICLE DILATED,RWMA LCX AKINETIC LAD RCA HYPOKINETIC CONCENTRIC LVH POSITIVE
EJECTION FRACTION
33 PERCENT IVC SIZE 0.82cm
COLLAPSING
IMPRESSION RVSP 48 PLUS 102 58mmHg MODERATE MR/AR/TR WITH PAH
RWMA LCH AKINETIC LAD AND RCA HYPOKINETIC
SEVERE LV DYSFUNCTION NO MS
DIASTOLIC
DYDFUNCTION , NO LV CLOT
CULTURE AND SENSTIVITY OF BLOOD - NO GROWTH AFTER 3 DAYS OF AEROBIC
INCUBATION
USG -ABDOMEN AND
PELVIS - NO SONOLOGICAL ABNORMALITY DETECTED
Treatment Given(Enter only
Generic Name)
INJ 25% DEXTROSE @30ML/HR STOP OHA/ INSULIN
INJ
LASIX 40MG IV/BD T.ECOSPRIN AV 75 10MG/PO/ HS
T. MET XL 25 MG PO/OD T.TELMA 40MG PO/OD
T. ALDACTONE
50MG PO/OD
SYRUP POTKLOR 15ML
IN GLASS OF WATER/ TID
Advice at Discharge
STOP OHA/ INSULIN
T.
LASIX 40MG IV/BD T.ECOSPRIN AV 75 10MG/PO/ HS
T. MET XL 25 MG PO/OD T.TELMA 40MG PO/OD
T. ALDACTONE 50MG
PO/OD
SYRUP POTKLOR
15ML IN GLASS OF WATER/ TID
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