202322006


Case History and Clinical Findings

CHIEF COMPLAINTS

37 YEAR OLD MALE PRESENTED TO CASUALITY WITH SOB SINCE 19/5/2023 MORNING

10:00AM

 

 

HOPI

 

PATIENT WAS APPARENTLY ASYMPTOMATIC 4DAYS BACK AND AFTER FRESEHEN UP HE DRANK RAGIJAVA AND TOOK MEDICATION PRESCRIBED BY US DURING DISCHARGE THEN HE SUDDENLY STARTED HAVING SOB GRADE 4

 

PAST ILLNESS

F/U/C/O SEPSIS SECONDARY TO LEFT LOWERLIMB CELLULITIS (RESOLVED) HFMEF (EF 48%) WITH AKI ON CKD WITH ANEMIA (NC/NC) SECONDARY TO ?CKD WITH THROMBOCYTOPENIA WITHN K/C/O DM2 SINCE 12 YEARS AND K/C/O HTN SINCE 2 YEARS

S/P RAYS AMPUTATION OF GREAT TOE S/P FASCIOTOMY LEFT FOOT 13/5/2023

3 SESSION OF HAEMODIALYSIS WERE DONE

 

 

PERSONAL HISTORY:

DIET-MIXED APPETITE -NORMAL

BOWEL AND BLADDER - REGULAR SLEEP-ADEQUATE

ADDICTIONS- NO ALLERGIES- NONE

 

FAMILY HISTORY:

INSIGNIFICANT

 

 

GENERAL EXAMINATION:

PATIENT IS CONSIOUS ,COHERENT ,COPERATIVE

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY VITALS:

TEMP-97.9F

BP- 120/80MMHG PR-104BPM

RR-28CPM

SPO2-98% AT ROOM AIR GRBS-580

 

SYSTEMIC EXAMINATION:

CVS-S1 S2 HEARD NO MURMURS RS-BAE+ NVBS

P/A -SOFT NON TENDER,NO GUARDING,NO RIGIDITY, HERNIAL ORIFICES NORMAL

 

 

COURSE AT THE HOSPITAL:

PATEINT WAS ADMITTED I/V/O SOB GRADE 3 -4 INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE AND ON FURTHER EVALUATION,WAS FOUND TO HAVE HIGH SUGARS WITH GRBS 580 (URINE FOR KETONE BODIES- NEGETIVE) DUE TO NON COMPLIANCE TO MEDICATION WITH ABG SHOWING SEVERE METABOLIC ACIDOSIS ,INJ.NAHCO3 50MEQ IV STAT F/B 50MEQ IN 100ML NS. INJ.HAI 6U IV STAT GIVEN INFUSION 6ML/HR .INSULIN INFUSION GIVEN ACCORDING TO ALGORITHM 1 FOR 1 DAY LATER SHIFTED TO S/C INSULIN ACCORDING TO THE REQUIREMENT .TLC COUNT ELEVATED AND WAS STARTED ON INJ.PIPTAZ AND INJ METROGYL .SURGERY REFERAL WAS DONE ON 19/5/23 I/V/O LEFT LOWER LIMB S/P FASCIOTOMY ,SKIN OVER THE LEFT LIMB EDEMATOUS AND SHINY ERYTHEMA +,LOACL RISE OF TEMP+ EXTENDING TILL MID THIGH TO FOOT AND FASCIOTOMY INCISION PRESENT OVER MID THIGH,GRANULATION TISSUE PRESENT

,MINIMAL SLOUGH +,SEROUS DISCHARGE PRESENT FROM FASCIOTOMY SITE AND ADVICE FOLLWED AS PER ORDERDS AND REGULAR DRESSINGS WITH MGSO4 +GLYCERINE DRESSING DONE

ON DAY 2 PATEINT HAS LOOSE STOOLS (? ANTIBIOTICS INDUCED DIARRHEA AND ANTIBIOTICS STOPPED)

ON DAY3 ANTIBIOTICS STOPPED AND MANAGED CONSERVATIVELY ON 21/5/23 .PATIENT HAS BEEN TAKEN TO DIALYSIS 1ST SESSION WITH 2FFPS AND 1PRBC TRANSFUSION,(? UREMIC ENCEPHALOPATHY AND ANURIA)

PREVIOUS H/O SEPSIS SECONDARY TO LEFT LOWER LIMB CELLULITIS WITH HEART FAILURE WITH PRESERVED EJECTION FRACTION WITH AKI ON CKD WITH ANEMIA (NC/NC) WITH THROMBOCYTOPENIA

PATIENT WAS DISCHARGED WITH VITALS TEMP-98.5

BP-140/70 PR 100BPM RR-16CPM SPO2-98%

GRBS -201 AT 8:00AM

PATIENT IS ADVISED FOR FOLLOWING I/V /O MAINTAINANCE OF HEMODIALYSIS

 

Investigation

19/5/2023 20/5/2023 21/5/2023 22/5/2023 23/5/23

HAEMOGRAM

HB-5.4 4.9 4.9 5.5 4.4

TLC-25000 12000 9400 9990 14770

RBC COUNT-1.90 1.75 1.71 1.86 1.51

PTL COUNT -50000 80000 50000 33000 35000

Treatment Given(Enter only Generic Name)

1. INJ.BICARBONATE 50MEQ IV STAT SLOW OVER 10MINS 50 MEQ IN 100ML NS OVER 30MINS

2. INJ. HAI 6U IV STAT F/B INFUSION @ 6ML/HR

3.  VF NS@ 75ML/HR

4. INJ.PANTOP 40MG 1V OD

5. INJ LASIX 20MG IV BD (SBP>110MMHG)

6. INJ.PIPTAZ 2.25GM IV /TID

7. INJ.METROGYL 500MG IV TID

8. TAB.NODOSIS 500MG PO/OD

9. INJ HAI 10U TID INJ.NPH 8U BD

10. TAB SPOROLAC DS PO/BD

11. TAB OROFER XT PO/OD

12. INJ VANCOMYCIN 250MG IV BD

13. TAB RACECATODRIL100MG PO/TID

14. 14.

Advice at Discharge

1. TAB PAN 40MG PO/OD

2. TAB LASIX 40MG PO/OD

3. TAB.NODOSIS 500MG PO/BD

4. TAB.OROFER XT PO/OD

5. TAB.SPOROLAC DS PO/TID

6. TAB RECECOTODRIL 100MG PO/TID


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