Cardiac Arrhythmia ProJR (Case 26-50)

 

50 THESIS CASES

CASE NO : 26

65years/MALE

D. O. A : 04/07/2025

D. O. D : 07/07/2025

Diagnosis

CEREBRO VASCULAR ACCIDENT WITH RIGHT HEMIPARESIS (ISCHAEMIC STROKE)

NON VASCULAR ATRIAL FIBRILLATION WITH CONTINUOUS VENTRICULAR RATE

K/C/O TYPE 2 DIABTETS MELLITUS AND HYPERTENSION SINCE 5 MONTHS

RIGHT INDIRECT INGUINAL HERNIA

Case History and Clinical Findings

CHIEF COMPLAINTS

C/O WEAKNESS OF RIGHT UPPERLIMB AND LOWER LIMB SINCE 3 DAYS

HISTORY OF PRESENTING ILLNESS

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO THE DEVELOPED WEAKNESS OF

RIGHT UPPER LIMB AND LOWER LIMB WEAKNESS SUDDEN ONSET , WHILE SLEEPING ON

BED

WEAKNESS IMPROVED NOW

NO H/O WEAKNESS OF OTHER LIMBS

NO H/O SLURRING OF SPEECH SINCE 3 DAYS

NO H/O DEVIATION OF MOUTH , LOSS OF VISION

H/O OF DIFFICULTY IN SWALLOWING

NO H/O SEIZURE LIKE ACTIVITY

NO H/O HEADACHE , GIDDINESS , NAUSEA , VOMITING.

NO H/O URINARY AND FECAL INCONTINENCE

H/O WEAK STRAEM OF URINE , DRIBBLING OF URINE

PERSONAL HISTORY:

MARRIED, NORMAL APPETITE,MIXED DIET ,REGULAR BOWEL AND BLADDER MOVEMENTS

,NORMAL MICTURITION ,NO ALLERGIES ,SLEEP ADEQUATE ,NO ADDICTIONS

FAMILY HISTORY: NOT SIGNIFICANT

GENREAL EXAMINATION: NO PALLOR ,ICTERUS, CYANOSIS,CLUBBIG ,

LYMPHADENOPATHY, MALNUTRITION

VITALS:-

TEMP: AFEBRILE, BP: 130/80 MMHG, RR: 16CPM, PR:76 BPM, SPO2: 98% AT RA.

SYSTEMIC EXAMINATION:- CVS- S1,S2 HEARD , NO MURMURS. RS- BAE+, NVBS. P/A: SOFT,

NON TENDER.

CNS :- HIGHER MENTAL FUNCTIONS INTACT, NO FOCAL NEUROLOGICAL DEFICIT

MRI WAS DONE ON 5/7/25 IMPRESSION- SMALL ACUTE INFARCT IN LEFT HEMIPONS

EXTENDING IN TO PONTOMEDULLARY JUNCTION

2D ECHO WAS DONE ON 5/7/25

IMPRESSION -MODERATE TR WITH PAH,MODERATE MR,MILD AR,TRIVIAL PR

RWMA +LAD HYPOKINESIS,NO AS/MS.CALCIFIED AV

MILD LV DYSFUNCTION +

GRADE II DIASTOLIC DYSFUNCTION ,NO PE,NO LV CLOT

Investigation

SEROLOGY -NEGATIVE

APTT TEST 32 Sec

BLEEDING TIME 2 Min 00 sec CLOTING TIME 4 Min 00 sec

HAEMOGLOBIN 13.4 gm/dl 13.0 - 17.0 Colorimetric LOX -PAPTOTAL COUNT 5,600 cells/cumm

4000 - 10000 ImpedenceNEUTROPHILS 50 % 40 - 80 Light MicroscopyLYMPHOCYTES 38 % 20 -

40 Light MicroscopyEOSINOPHILS 02 % 1 - 6 Light MicroscopyMONOCYTES 10 % 2 - 10 Light

MicroscopyBASOPHILS 0 % 0 - 2 Light MicroscopyPLATELET COUNT 2.11 lakhs/cu.mm 1.5-4.1

ImpedenceSMEAR Normocytic normochromic

HbA1c 6.5 %

Total Bilurubin 0.60 mg/dl 0 - 1 Jendrassic &Groff'sDirect Bilurubin 0.17 mg/dl 0.0 - 0.2 Jendrassic

&Groff'sSGOT(AST) 21 IU/L 0 - 35 Modified IFCCSGPT(ALT) 11 IU/L 0 - 45 Modified

IFCCALKALINEPHOSPHATASE211 IU/L 56 - 128 PNPP-DEATOTAL PROTEINS 6.3 gm/dl 6.4 - 8.3

BiuretALBUMIN 3.86 gm/dl 3.2 - 4.6 BCGA/G RATIO 1.58

UREA 23 mg/dl 17 - 50 Urease-GLDHCREATININE 0.8 mg/dl 0.8 - 1.3 Modified Jaffe'sURIC ACID

4.0 mmol/L 3.5 - 7.2 Uricase-POD WithDHBSCALCIUM 10.0 mg/dl 8.6 - 10.2 Arsenazo

IIIPHOSPHOROUS 3.7 mg/dl 2.5 - 4.5 Direct UV withoutreductionSODIUM 137 mmol/L 136 - 145 Ion

SelectiveElectrodePOTASSIUM 3.4 mmol/L. 3.5 - 5.1 Ion SelectiveElectrodeCHLORIDE 98 mmol/L

98 - 107

Prothrombin Time 16 Sec 10-16secINR 1.11Total Bilurubin 0.58 mg/dl 0 - 1 Jendrassic &Groff'sDirect

Bilurubin 0.17 mg/dl 0.0 - 0.2 Jendrassic &Groff'sSGOT(AST) 17 IU/L 0 - 35 Modified

IFCCSGPT(ALT) 11 IU/L 0 - 45 Modified IFCCALKALINEPHOSPHATASE177 IU/L 56 - 128 PNPPDEATOTAL PROTEINS 5.2 gm/dl 6.4 - 8.3 BiuretALBUMIN 3.16 gm/dl 3.2 - 4.6 BCGA/G RATIO 1.55

UREA 20 mg/dl 17 - 50 Urease-GLDHCREATININE 0.7 mg/dl 0.8 - 1.3 Modified Jaffe'sURIC ACID

4.0 mmol/L 3.5 - 7.2 Uricase-POD WithDHBSCALCIUM 9.3 mg/dl 8.6 - 10.2 Arsenazo

IIIPHOSPHOROUS 3.4 mg/dl 2.5 - 4.5 Direct UV withoutreductionSODIUM 138 mmol/L 136 - 145 Ion

SelectiveElectrodePOTASSIUM 3.6 mmol/L. 3.5 - 5.1 Ion SelectiveElectrodeCHLORIDE 99 mmol/L

98 - 107

Treatment Given(Enter only Generic Name)

TAB.ECOSPRIN AV 75MG/20MG PO/HS 0-0-1

TAB PANTOP 40MG PO/OD/BBF

TAB TELMA 40MG PO/OD 1-0-0

TAB GLIMI M1 PO/OD 1-0-0

TAB DABIGATRAN 110MG PO/BD 1-0-1

TAB.METOPROLOL 25MG PO/OD 1-0-0

Advice at Discharge

TAB.ECOSPRIN AV 75MG/20MG PO/HS 0-0-1 XTO BE CONTINUED

TAB PANTOP 40MG PO/OD/BBF X5DAYS

TAB TELMA 40MG PO/OD 1-0-0 XTO BE CONTINUED

TAB GLIMI M1 PO/OD 1-0-0 XTO BE CONTINUED

TAB DABIGATRAN 110MG PO/BD 1-0-1 XTO BE CONTINUED

TAB.METOPROLOL 25MG PO/OD 1-0-0 XTO BE CONTINUED

Follow Up

REVIEW GM OPD AFTER 2WEEK

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 27

70years/MALE

D. O. A : 14/06/2025

D. O. D : 25/06/2025

Diagnosis

GTCS SECONDARY TO ACUTE ISCHEMIC STROKE LEFT CEREBLLAR HEMORRHAGIC

INFARCT

TYPE 1 RESPIRATORY FAILURE S/P MECHANICAL VENTILLATION EXTUBATED ON 20-6-25

9AM

GTCS WITH LEFT HEMIPLEGIA

K/C/O COPD SINCE 20 YRS ,HTN SINCE 3 YRS

ATRIAL FIBRILLATION WITH FVR

PRE RENAL AKI [RESOLVED ]

BEDSORE GRADE 3 [SACRUM BUTTOCKS REGION ]

Case History and Clinical Findings

ED ON 20-6-25 AND WAS SHIFTED TO AMC.PATIENTS VITALS ARE BEING STABLE AND

BEING DISCHARGED

PATIENT WAS TAKEN TO A NEAR BY HOSPITAL AND CT BRAIN WAS DONE . HE WAS

INTUBATED I/V/O [INCREASED SOB , ]

N/H/O CHEST PAIN, PALPITATION ,ORTHOPNEA, PND ,HEADACHE,GIDDINESS, BOV

,DILPOPIA, NAUSEA, VOMITING , PEDAL EDEMA ,DECREASED URINE OUTPUT

C/O ALTERED SENSORIUM SINCE 1 DAY

INVOLUNTARY MOVEMENTS OF UPPER AND LOWER LIMBS

C/O 1 SEIZURE EPISODE SINCE 1 DAY

C/O FEVER SINCE 1 DAY

HISTORY OF PRESENTING ILLNESS:

PATIENT WAS APPARENTLY ASSYMPTOMATIC SINCE 6 DAYS THEN HE DEVELOPED FEVER

WHICH WAS SUDDEN IN ONSET GRADUALLY PROGRESSIVE HIGH GRADE A/W CHILLS AND

RIGORS ,1 EPISODE OF TONIC CLONIC INVOLUNTARY MOVEMENTS OF UPPER AND LOWER

LIMB ON 14 /06/2025 @4PM WITH UPROALLING OF EYEBALLS BOWEL INCONTINENCE AND

LOC .

K/C/O HTN SINCE 3 YRS ON TAB. AMLARD.AT 5/50MG

K/C/O BRONCHIAL ASTHMA SINCE 20 YRS NOT USING ANY INHALER

H/O RIGHT EYE CATARACT SURGERY 1 YR AGO

N/K/C/O T2 DM , TB, EPILEPSY ,ASTHMA COPD, CVA , CAD

PERSONAL HISTORY:MIXED DIET, APPETITE NORMAL, BOWEL MOVEMENTS- NORMAL ,

MICTURITION NORMAL, NO KNOWN ALERGIES AND HABITS-ALCOHOL SINCE YEARLY ONCE

OR TWICE FOR 5 YRS

FAMILY HISTORY:NOT SIGNIFICANT

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS , COHERENT , ORIENTED TO TIME,PLACE , PERSON

MILD PALLOR, NO ICTERUS, CYANOSIS, CLUBBING ,LYMPHADENOPATHY, PEDAL EDEMA

VITALS:- TEMP: AFEBRILE, BP: 160/90 MMHG, RR: 14CPM, PR:104 BPM, SPO2: 100% AT RA,

GRBS :261 MG%

SYSTEMIC EXAMINATION:

CVS:S1 S2 HEARD ,NO MURMURS

PA:SOFT

CNS: PUPILS REACTING TO LIGHT

RS-NVBS (+) BAE(+)

GCS: E1VT M3

TONE RT LT

 UL N N

 LL N N

POWER : COULDNOT BE ELICITED

REFLEXES :COULD NOT BE ELICITED

NEUROSURGERY OPINION WAS TAKEN ON 18/06/25 I/V/O ACUTE HEMORRHAGIC INFARCT

PLAIN MRI SCAN OF BRIAN WAS DONE :

LARGE FLAIR HYPERTENSE AREA SEEN INVOLVING LEFT CEREBELLAR HEMISPHERE

EXTENDING TO LEFT MIDDLE CEREBELLAR PEDUNCLE , LEFT CEREBELLAR TONSIL WITH

AREAS OF DIFFUSION RESTRICTION . FEW TINY INTERNAL ACUTE HEMORRHAGIC FOCI

ARE SEEN . THERE IS MASS EFFECT RESULTING IN PARTIAL EFFACEMENT OF FOURTH

VENTRICLE WITH RESULTANT MILD UPSTREAM DILATATION OF THIRD VENTRICLE AND B/L

AND LATERAL VENTRICLES .MILD INDENTATION OF POSTERIOR ASPECT OF MEDULLA

OBLONGATA . MILD CAUDAL DESCENT OF CEREBELLAR TONSIL -S/O -ACUTE HEMORRAGIC

EFFECT

TINY AVUTE INFARCT IS SEEN IN THE SUBCORTICAL WHITE MATTER OF RIGHT FRONTAL

LOBE

TINY CHRONIC INFARCT IN PONS

OPTHAL REFFERAL WAS SENT I/V/O RAISED ICP AND FUNDOSCOPY CHANGES:

 RE LE

VA PATIENT IS UNCONSCIOUS

LIDS N N

CONUCTIVA MUDDY MUDDY

CORNEA CLEAR CLEAR

IRIS NCP NCP

PUPIL NSRL NSRL

LENS IMSC GRADE 2 PSEUDOPHALUS

 FUNDUS

MEDIA HAZY CLEAR

OD N SIZE ,CIRCULAR WELL DEFINED MARGIN

CDR 0.2-3:1HNRR

VESSELS N N

MACULA FR NOT SEEN FR NOT SEEN

PATIENT WAS REFFERED TO GENERAL SURGERY DEPARTMENT I/V/O BED SORES

MULTIPLE VESICLES AND FEW BULLAE LARGEST MEASURING 1X1 CM NOTED OVER

MEDIAL ASPECT OF RIGHT ARM

NIKOLSKY NEGATIVE

ULTRASOUND REPORT:

E/O FEW CALCULI NOTED IN LEFT KIDNEY WITH LARGEST

E/O FEW SUBCENTIMETRIC CYSTS NOTED IN LEFT KIDNEY

E/O 15X14MM CYST NOTED IN THE UPPER POLE OF RIGHT KIDNEY

IMPRESSION:

GRADE 1 RPD CHANGES IN RIGHT KIDNEY

GRADE2 RPD CHANGES IN LEFT KIDNEY

B/L RENAL CORTICAL CYST

LEFT RENAL CALCULI

COURSE IN THE HOSPITAL

PATIENT WAS BROUGHT TO CASUALTY ON 14-6-25 (INTUBATED OUTSIDE) WITH C/O

ALTERED SENSORIUM,INVOLUNTARY MOVEMENTS OF UL AND LL,FEVER.PATIENT HISTORY

WAS TAKEN AND WAS EXAMINED .SURGERY REFERAL WAS DONE I/V/O BEDSORES AND

DEBRIDEMENT WAS DONE,NEUROSURGERY REFERAL WAS DONE AND CONSERVATIVE

MANAGEMENT WAS FOLLOWED,CARDIOLOGY REFERAL WAS DONE I/V/O

AF,DERMATOLOGY REFERAL WAS DONE ON 17-6-25 I/V/O FRICTIONAL BLISTERS AND

FUDIC CREAM WAS GIVEN.NECESARY INVESTIGATIONS WERE DONE AND

ANTIBIOTICS,FLUIDS,ANALGESICS WERE GIVEN.PATIENT WAS EXTUBATED.

Investigation

HBsAg-RAPID 14-06-2025 04:47:PM Negative

Anti HCV Antibodies - RAPID 14-06-2025 04:47:PM Non ReactiveRFT 14-06-2025 04:47:PMUREA

82 mg/dlCREATININE 2.0 mg/dlURIC ACID 6.2 mmol/LCALCIUM 9.8 mg/dlPHOSPHOROUS 5.6

mg/dlSODIUM 136 mmol/LPOTASSIUM 3.5 mmol/L.CHLORIDE 100 mmol/L

ABG 14-06-2025 04:47:PMPH 7.34PCO2 25.7PO2 265HCO3 13.6St.HCO3 16.5BEB -10.3BEecf -

11.0TCO2 27.2O2 Sat 32.2O2 Count 19.7LIVER FUNCTION TEST (LFT) 14-06-2025 04:47:PMTotal

Bilurubin 2.49 mg/dlDirect Bilurubin 0.65 mg/dlSGOT(AST) 155 IU/LSGPT(ALT) 120 IU/LALKALINE

PHOSPHATASE 122 IU/LTOTAL PROTEINS 6.5 gm/dl lALBUMIN 4.10 gm/dlA/G RATIO 1.71

COMPLETE URINE EXAMINATION (CUE) 14-06-2025 04:47: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 NilABG 14-06-2025

10:14:PMPH 7.33PCO2 27.7PO2 131HCO3 14.4St.HCO3 16.7BEB -9.8BEecf -10.3TCO2 29.5O2

Sat 98.5O2 Count 16.9

RFT 14-06-2025 11:38:PMUREA 103 mg/dlCREATININE 2.5 mg/dlURIC ACID 6.2 mmol/LCALCIUM

9.8 mg/dlPHOSPHOROUS 5.37 mg/dlSODIUM 139 mmol/LPOTASSIUM 3.9 mmol/L.CHLORIDE 108

mmol/LABG 14-06-2025 11:38:PMPH 7.26PCO2 31.9PO2 43.6HCO3 14.4St.HCO3 15.1BEB -

11.4BEecf -11.4TCO2 30.0O2 Sat 72.5O2 Count 11.4

COMPLETE URINE EXAMINATION (CUE) 15-06-2025 09:46:AMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN ++SUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 6-8EPITHELIAL CELLS 2-4RED BLOOD CELLS 2-

3CRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilABG 15-06-2025

09:56:PMPH 7.309PCO2 24.5PO2 130HCO3 11.9St.HCO3 14.4BEB -12.8BEecf -13.1TCO2 25.5O2

Sat 98.9O2 Count 13.2

RFT 15-06-2025 09:56:PMUREA 87 mg/dlCREATININE 1.7 mg/dlURIC ACID 4.2 mmol/LCALCIUM

9.0 mg/dlPHOSPHOROUS 3.6 mg/dlSODIUM 143 mmol/LPOTASSIUM 4.2 mmol/L.CHLORIDE 106

mmol/LABG 16-06-2025 11:25:PMPH 7.356PCO2 23.8PO2 101HCO3 13.0St.HCO3 15.8BEB -

10.9BEecf -11.5TCO2 27.4O2 Sat 98.0O2 Count 13.4

RFT 16-06-2025 11:25:PMUREA 85 mg/dlCREATININE 1.4 mg/dlURIC ACID 3.8 mmol/LCALCIUM

9.0 mg/dlPHOSPHOROUS 2.0 mg/dlSODIUM 148 mmol/LPOTASSIUM 3.7 mmol/L.CHLORIDE 101

mmol/LABG 17-06-2025 11:45:PMPH 7.375PCO2 23.9PO2 66.6HCO3 13.6St.HCO3 16.4BEB -

10.0BEecf -10.6TCO2 28.7O2 Sat 93.6O2 Count 12.5

LIVER FUNCTION TEST (LFT) 17-06-2025 11:45:PMTotal Bilurubin 0.99 mg/dlDirect Bilurubin 0.18

mg/dlSGOT(AST) 86 IU/LSGPT(ALT) 63 IU/LALKALINE PHOSPHATASE 119 IU/LTOTAL

PROTEINS 4.7 gm/dlALBUMIN 2.93 gm/dlA/G RATIO 1.66RFT 17-06-2025 11:45:PMUREA 74

mg/dlCREATININE 1.6 mg/dlURIC ACID 3.9 mmol/LCALCIUM 9.4 mg/dlPHOSPHOROUS 2.0

mg/dlSODIUM 149 mmol/LPOTASSIUM 3.6 mmol/L.CHLORIDE 106 mmol/L

HAEMOGLOBIN 9.9 gm/dl TOTAL COUNT 7,800 cells/cumm NEUTROPHILS 84 %LYMPHOCYTES

11 %EOSINOPHILS 00 % MONOCYTES 05 % BASOPHILS 00 % PCV 30.5 vol % M C V 95.2 fl M C

H 31.0 pg M C H C 32.5 % RDW-CV 14.9 %RDW-SD 53.0 fl RBC COUNT 3.20 millions/cumm

PLATELET COUNT 74,000 lakhs/cu.mm SMEARRBC Normocytic normochromicWBC With in normal

limits PLATELETS decreased HEMOPARASITES No hemoparasitesIMPRESSION Normocytic

normochromic anemiawith thrombocytopenia2D ECHO WAS DONE ON 18/06/25

TACHYCARDIA DURING STUDY

VPL1ST DURING STUDY

CONCENTRIC LVH +

GLOBAL HYPOKINESIA

MILD TO MODERATE TR WITH PAH

TRIVIAL MR/MILD AR NO PR

SCLEROTIC AV ;NO AS/MI ;IAS-INTACT

EF>48% MILD LV DYSFUNCTION

GRADE 1 DIASTOLIC DYSFUNCTION

MINIMAL PE ;NO LV CLOT

IVC SIZE [1.0CMS ]COLLAPSING

ABG DONE ON 18-6-25PH 7.416 7.35-7.45PCO2 24.0 mmHg PO2 81.6 mmHg HCO3 15.1

mmol/LSt.HCO3 18.1 mmol/LBEB -7.8 mmol/LBEecf -8.6 mmol/LTCO2 31.2 VOLO2 Sat 96.5 %O2

Count 14.0 vol %

HAEMOGLOBIN 9.9 gm/dl TOTAL COUNT 7,800 cells/cumm NEUTROPHILS 84 %

LYMPHOCYTES 11 %EOSINOPHILS 00 % MONOCYTES 05 % BASOPHILS 00 % PCV 30.5 vol %

M C V 95.2 fl M C H 31.0 pg M C H C 32.5 %RDW-CV 14.9 % RDW-SD 53.0 fl RBC COUNT 3.20

millions/cumm PLATELET COUNT 74,000 lakhs/cu.mmRBC Normocytic normochromic WBC With in

normal limitsPLATELETS decreased counts on smear HEMOPARASITES No hemoparasites seen

IMPRESSION Normocytic normochromic anemiawith thrombocytopenia

ABG DONE ON 18-6-25PH 7.375 7.35-7.45PCO2 23.9 mmHg 35-45 mmHgPO2 66.6 mmHg 85-95

mmHgHCO3 13.6 mmol/LSt.HCO3 16.4 mmol/LBEB -10.0 mmol/LBEecf -10.6 mmol/LTCO2 28.7

VOLO2 Sat 93.6 %O2 Count 12.5 vol %

LFT DONE ON 18-6-25 Total Bilurubin 0.99 mg/dl ,Direct Bilurubin 0.18 mg/dl ,SGOT(AST) 86

IU/L,SGPT(ALT) 63 IU/L ALKALINE PHOSPHATASE 119 IU/L ,TOTAL PROTEINS 4.7

gm/dl,ALBUMIN 2.93 gm/dl,A/G RATIO 1.66

RFT DONE ON 18-6-25 UREA 74 mg/dl ,CREATININE 1.6 mg/dl ,URIC ACID 3.9 mmol/L ,CALCIUM

9.4 mg/dl,PHOSPHOROUS 2.0 mg/dl ,SODIUM 149 mmol/L ,POTASSIUM 3.6 mmol/L,CHLORIDE

106 mmol/L

ABG DONE ON 19-6-25 PH PCO2 28.6 mmHg ,PO2 166 mmHg ,HCO3 16.8 mmol/L,St.HCO3 18.9

mmol/L,BEB -6.8 mmol/L,BEecf -7.3 mmol/L,TCO2 35.0 VOL,O2 Sat 99.2 %O2 Count 14.1 vol %

COMPLETE URINE EXAMINATION (CUE) DONE ON 19-6-25COLOUR Pale yellow ,APPEARANCE

Clear ,REACTION Acidic ,SP.GRAVITY 1.010 ,ALBUMIN Trace,SUGAR Nil ,BILE SALTS Nil ,BILE

PIGMENTS Nil ,PUS CELLS 2-3,EPITHELIAL CELLS 2-3,RED BLOOD CELLS Nil,CRYSTALS Nil

,CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil

HAEMOGLOBIN 10.3 gm/dl TOTAL COUNT 6,500 cells/cumm NEUTROPHILS 84 %

LYMPHOCYTES 09 %EOSINOPHILS 01 %MONOCYTES 06 % BASOPHILS 00 % PCV 31.2 vol %

M C V 95.0 fl M C H 31.3 pg M C H C 32.9 % RDW-CV 14.4 % RDW-SD 50.4 flRBC COUNT 3.2

millions/cumm PLATELET COUNT 1.1 lakhs/cu.mmRBC Normocytic normochromic WBC With in

normal limits PLATELETS inadeqauteHEMOPARASITES No hemoparasites seenIMPRESSION

Normocytic normochromic anemiawith thrombocytopenia

RFT DONE ON 19-6-25UREA 109 mg/dl CREATININE 1.6 mg/dl URIC ACID 5.9 mmol/LCALCIUM

9.5 mg/dl PHOSPHOROUS 2.8 mg/dl SODIUM 145 mmol/L POTASSIUM 3.7 mmol/L.CHLORIDE

106 mmol/L

CALCIUM 8.8 mg/dl.

SERUM MAGNESIUM 2.1 mg/dl

ABG DONE ON 19-6-25 PH 7.39PCO2 28.0 mmHg PO2 131 mmHg HCO3 16.9 mmol/LSt.HCO3

19.0 mmol/LBEB -6.6 mmol/LBEecf -7.0 mmol/LTCO2 35.8 VOLO2 Sat 98.7 %O2 Count 12.4 vol %

HAEMOGLOBIN 9.6 gm/dl TOTAL COUNT 5,500 cells/cumm NEUTROPHILS 70 %

LYMPHOCYTES 20 % EOSINOPHILS 02 %MONOCYTES 08 % BASOPHILS 00 % PCV 28.7 vol %

M C V 92.6 fl M C H 31.0 pg M C H C 33.4 % RDW-CV 13.2 % RDW-SD 45.6 fl RBC COUNT 3.1

millions/cumm PLATELET COUNT 1.4 lakhs/cu.mm RBC Normocytic normochromic WBC With in

normal limits PLATELETS Adequate in number and distribution HEMOPARASITES No

hemoparasites seenIMPRESSION Normocytic normochromic anemia

ABG DONE ON 29-6-25 PH 7.32PCO2 36.8 mmHg PO2 33.6 mmHg HCO3 18.4 mmol/LSt.HCO3

18.5 mmol/LBEB -6.5 mmol/LBEecf -6.5 mmol/LTCO2 39.9 VOLO2 Sat 55.6 %O2 Count 6.9 vol %

RFT DONE ON 20-6-25 UREA 78 mg/dl CREATININE 1.4 mg/dl URIC ACID 5.7 mmol/L CALCIUM

9.4 mg/dlPHOSPHOROUS 2.1 mg/dl SODIUM 152 mmol/L POTASSIUM 3.2 mmol/LCHLORIDE 110

mmol/L

ABG DONE ON 20-6-25 9 55AM PH 7.41 PCO2 27.8 mmHg PO2 137 mmHg HCO3 17.3

mmol/LSt.HCO3 19.4 mmol/LBEB -6.1 mmol/LBEecf -6.5 mmol/LTCO2 36.7 VOLO2 Sat 99.1 %O2

Count 11.5 vol %

APTT TEST 21-6-25 35 Sec

Prothrombin Time 18 Sec INR 1.33

HAEMOGLOBIN 8.8 gm/dl TOTAL COUNT 3,000 cells/cumm NEUTROPHILS 46 %

LYMPHOCYTES 38 %EOSINOPHILS 06 % MONOCYTES 10 % BASOPHILS 00 %PCV 27.0 vol %

M C V 94.4 fl M C H 30.7 pg M C H C 32.5 % RDW-CV 13.4 % RDW-SD 46.5 fl RBC COUNT 2.85

millions/cummPLATELET COUNT 1.64 lakhs/cu.mm RBC Normocytic normochromicWBC decreased

in countPLATELETS Adequate in number and distributionHEMOPARASITES No hemoparasites seen

IMPRESSION Normocytic normochromic anemia

UREA 48 mg/dl 17 - 50 CREATININE 1.2 mg/dl URIC ACID 4.1 mmol/L CALCIUM 9.3 mg/dl

PHOSPHOROUS 2.5 mg/dl SODIUM 136 mmol/L POTASSIUM 3.6 mmol/L.CHLORIDE 101 mmol/L

PH 7.39 PCO2 29.6 mmHg PO2 73.0 mmHg HCO3 17.5 mmol/LSt.HCO3 19.3 mmol/LBEB -6.1

mmol/LBEecf -6.5 mmol/LTCO2 37.0 VOLO2 Sat 95.4 %O2 Count 12.0 vol %

APTT TEST 23-6-25 33 Sec

BLEEDING TIME 2 Min 30 CLOTING TIME 4 Min

Prothrombin Time 17 Sec INR 1.2

HAEMOGRAM DONE ON 24-6-25 5 55AM HAEMOGLOBIN 7.4 gm/dl TOTAL COUNT 2,200

cells/cumm NEUTROPHILS 58 % LYMPHOCYTES 26 % EOSINOPHILS 06 % MONOCYTES 10 %

BASOPHILS 00 %PCV 21.9 vol % M C V 91.5 fl M C H 31.0 pgM C H C 33.9 % RDW-CV 13.9

%RDW-SD 48.7 fl RBC COUNT 2.39 millions/cumm PLATELET COUNT 1.72

lakhs/cu.mmSMEARRBC Normocytic normochromic WBC Decreased on smearPLATELETS

Adequate in number and distribution HEMOPARASITES No hemoparasites seen IMPRESSION

Normocytic normochromic Anemia

RFT DONE ON 24-6-25 UREA 50 mg/dl CREATININE 1.3 mg/dl URIC ACID 1.6 mmol/L CALCIUM

8.3 mg/dlPHOSPHOROUS 2.8 mg/dl SODIUM 135 mmol/L POTASSIUM 3.9 mmol/L. CHLORIDE 99

mmol/L 98 - 107

HAEMOGRAM DONE ON 25-6-25 HAEMOGLOBIN 7.3 gm/dl TOTAL COUNT 5,800

cells/cummNEUTROPHILS 72 % LYMPHOCYTES 15 % EOSINOPHILS 03 % MONOCYTES 10 %

BASOPHILS 00 % PCV 20.6 vol % M C V 89.2 fl M C H 31.6 pg M C H C 35.4 % RDW-CV 12.6 %

RDW-SD 41.8 fl RBC COUNT 2.31 millions/cumm PLATELET COUNT 2.20

lakhs/cu.mmSMEARRBC Normocytic normochromic WBC With in normal limitsPLATELETS

Adequate in number and distribution HEMOPARASITES No hemoparasites seen

RFT DONE ON 25-6-25 UREA 40 mg/dl CREATININE 1.4 mg/dl URIC ACID 2.6 mmol/LCALCIUM

8.6 mg/dl PHOSPHOROUS 2.7 mg/dlSODIUM 138 mmol/L POTASSIUM 4.2 mmol/L.CHLORIDE 102

mmol/L

HAEMOGLOBIN 7.1 gm/dl TOTAL COUNT 4,600 cells/cummNEUTROPHILS 90 % LYMPHOCYTES

05 %EOSINOPHILS 01 % MONOCYTES 04 % BASOPHILS 00 % PCV 20.0 vol % M C V 85.5 fl M C

H 30.3 pgM C H C 35.5 % RDW-CV 13.7 % RDW-SD 43.6 fl RBC COUNT 2.34 millions/cumm

PLATELET COUNT 4.0 lakhs/cu.mmSMEARRBC Normocytic normochromic WBC With in normal

limits withneutrophiliaPLATELETS Adequate in number and distributionNo hemoparasites seen

IMPRESSION Normocytic normochromic anemiawith neutrophilia

SERIAL DAILY ECGS DONE

ECG DONE ON 16/6/25 SHOWD NO IDENTIFIABLE P WAVES

IRREGULARLY IRREGULAR RYTHM AND HAS HEARTRATE OF 150BPM AND HAS BEEN

DIAGNOSED AS ATRIAL FIBRILLATION WITH FVR

Treatment Given(Enter only Generic Name)

INJ.MONOCEF 1GIV/BD INJ .ARTESUNATE 120MG IV/BDIVF -3%NS@15ML/HRINJ .PAN40MG

IV/ODINJ .MIDAZ @ 3ML/HRINJ ATRACOINJ.LEVIPIL 500MG IV/BDRVAM 50MG +50ML NS

@3ML /HRINJ. LMWH 60MIVF NS@50ML/HRG S/C ODINJ.HYDROCORT 100MG

IV/BDTAB.ECOSPRIN AV 75MG /20MG RT/HSTAB.BISOPROLOL 2.5 MG RT/BDINJ. METXL 2ML

IN 8ML NS IV /STAT

Advice at Discharge

RT FEEDS -100ML WATER 2ND HOURLY,200ML MILK WITH PROTEIN POWDER 4TH HOURLY

IVF 0.9NS/DNS @100ML/HR ALTERNATIVELY

TAB LEVIPIL 500MG RT/BD TO BE CONTINUED

TAB METROGYL 500MG RT/BD 5 DAYS

TAB FEROPENEM 200MG RT/BD 5DAYS

TAB DILTIAZEM 30MG RT/TID FOR 2 WEEKS

TAB ATORVASTATIN 20MG RT/HS TO BE CONTINUED

 TAB PAN 40MG RT/OD 5 DAYS

TAB.OROFER -XT PO/OD FOR 1 MONTH

TAB. VITC PO/OD FOR 1 MONTH

OINT T BACT LA/BD

FUDIC CREAM L/A SOS

NEBS BUDECORT,IPRAVENT,MUCOMIST P/N TID

CHEST PHYSIOTHERAPY , POSITION CHANGE 2ND HOURLY

OINT THROMBOPHOBE L/A TID

ORAL HYGIENE

DAILY DRESSINGS FOR BEDSORE

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 28

80years/FEMALE

D. O. A : 05/06/2025

D. O. D : 14/06/2025

Diagnosis

ACUTE CVA -ICHEAMIC STROKE WITH LEFT HEMIPLEGIA WITH UMN TYPE FACIAL PALSY

INVOLVING RIGHT MCA TERRITORY -RIGHT FRONTO PARIETO TEMPORAL INFARCT

SECONDARY TO CARDIOEMBOLIC STROKE

RECURRENT CVA

ASPIRATION PNEUMONIA

ATRIAL FIBRILLATION WITH FVR (CONTROLLED)

CLINICAL MALARIA

PRERENAL AKI(RESOLVED)

K/C/O DM TYPE 2 (HBA1C- 7.6%) SINCE 4 YEARS

K/C/O HTN SINCE 4 YEARS

GRADE 2 BED SORE OVER LEFT GLUTEAL REGION

Case History and Clinical Findings

C/O ALTERED SENSORIUM ,SLURRED SPEECH ,WEAKNESS OF LEFT UPPER LIMB AND

LOWER LIMB SINCE 2 DAYS

HOPIPATIENT WAS APPARENTLY ALRIGHT 2 DAYS BACK THEN SHE DEVELOPED ALTERED

SENSORIUM ,APHASIAFOR WHICH SHE WAS TAKEN TO NEARBY HOSPITAL AND FOUND TO

BE HYPOGLYCEMIC AND GOTN TREATED LATER FOUND TO BE HAVING REDUCED

MOVEMENT OF LEFT HAND AND FOOT AND DEVIATION OF MOUTH WITH SLURRED SPEECH

NO H/O CHEST PAIN,CHEST TIGHTNESS

H/O SOB GRADE III SINCE 3 MONTHS, INVOLUNTARY MICTURATION,DEFECATION AND

PEDAL EDEMA

NO H/O ABDOMINAL PAIN

PAST HISTORY

K/C/O DM -VILDAGLIPTIN+METFORMIN(50/500) PO/OD

H/C/O HTN-TELMA AM SINCE 4 YEARS PO/OD

PERSONAL HISTORY: MIXED DIET, APPETITE NORMAL, REGULAR BOWEL MOVEMENTS,

MICTURITION NORMAL, NO KNOWN ALERGIES NO KNOWN ADDICTIONS

FAMILY HISTORY: NOT SIGNIFICANT

GENREAL EXAMINATION: PEDAL EDEMA PRESENT,PALLOR PRESENT

NO ICTERUS, CYANOSIS, LYMPHADENOPATHY, MALNUTRITION

VITALS:- TEMP: AFEBRILE, BP: 120/70 MMHG, RR: 16CPM, PR: 96 BPM, SPO2: 96% AT RA,

GRBS 148 MG%

SYSTEMIC EXAMINATION:- CVS-NORMAL, RS-NORMAL,PA: NORMAL

CNS:

GCS-E2V1M5

MOTOR:

 RT LT

POWER

 U/L 4/5 0/5

 L/L 4/5 0/5

TONE

 U/L NORMAL NORMAL

 L/L NORMAL NORMAL

REFLEXES

 RT LT

BICEPS +2 _

TRICEPS + _

SUPINATOR _ _

KNEE + _

ANKLE _ _

PLANTAR FLEXION EXTENSION

CRANIAL NERVES:

FASCIAL NERVE(7TH NERVE): NO DEVIATION OF MOUTH?

 NO DROOLING OF SALIVA

NIHSS STROKE SCALE:

ON 5/6/2025:MODERATE STROKE(14)

ON 6/6/2025:MODERATE STROKE(7)

SURGRY REFERRAL WAS DONE ON 10/6/25 I/V/O BED SORES ADVISED FOR ASD, POSITION

CHANGE 2 HRLY, ALPHA BED

CARDIOLOGY REFERRAL WAS DONE ON 9/6/25 I/V/O ATRIAL FIBRILLATION

COURSE IN HOSPITAL:80 YR OLD FEMALE CAME WITH THE ABOVE COMPLAINTS. PATIENT

WAS EVALUATED CLINICALLY WITH APPROPRIATE INVESTIGATIONS WAS DIAGNOSED AS

1.ACUTE CVA -ICHEAMIC STROKE WITH LEFT HEMIPLEGIA WITH UMN TYPE FACIAL PALSY

INVOLVING RIGHT MCA TERRITORY -RIGHT FRONTO PARIETO TEMPORAL INFARCT

SECONDARY TO CARDIOEMBOLIC STROKE 2.RECURRENT CVA 3.ASPIRATION PNEUMONIA

4.ATRIAL FIBRILLATION WITH FVR 5.CLINICAL MALARIA 6.PRERENAL AKI 7.K/C/O DM TYPE 2

(HBA1C- 7.6%) SINCE 4 YEARS 8.K/C/O HTN SINCE 4 YEARS. PATIENT WAS STARTED ON

INTRAVENOUS FLUIDS, RT FEEDS (MILK+PROTEIN POWDER).GRBS 7 POINT MONITORING

WAS DONE AND WAS STARTED ON INSULIN AND OHA. TEMPERATURE CHARTING WAS

DONE 4 HRLY I/V/O FEVER SPIKES PATIENT WAS STARTED ON ANTIBIOTICS INJ MONOCEF

2 GM IV/BD, INJ.AGUMENTIN 1.2GM IV/BD,INJ VANCOMYCIN 1.2 GM IV/TID, ANTIMALARIALS,

ANTIVIRALS, ANTIFUNGALS, ANTIPYRETICS.PATENT GCS IMPROVED AND IS

HEMODYNAMICALLY STABLE HENCE BEING DISCHARGED WITH RYLE'S TUBE, FOLEY'S

URINARY CATHETER AND CENTRAL LINE IN SITU.

Investigation

COMPLETE URINE EXAMINATION (CUE) 05-06-2025 COLOUR Pale yellow,APPEARANCE

Clear,REACTION Acidic,SP.GRAVITY 1.010,ALBUMIN +,SUGAR +,BILE SALTS Nil,BILE

PIGMENTS Nil,PUS CELLS 2-3,EPITHELIAL CELLS 3-4,RED BLOOD CELLS Nil,CRYSTALS

Nil,CASTS Nil,AMORPHOUS DEPOSITS Absent,OTHERS Nil

HBsAg-RAPID 05-06-202 NegativeAnti HCV Antibodies - RAPID 05-06-2025 Non Reactive

RFT 05-06-2025 ,UREA 21 mg/dl ,CREATININE 0.8 mg/dl ,URIC ACID 2.3 mmol/L ,CALCIUM 9.4

mg/dl ,PHOSPHOROUS 3.0 mg/dl ,SODIUM 137 mmol/L,POTASSIUM 2.8 mmol/L,CHLORIDE 101

mmol/L ABG 05-06-2025 PH 7.41,PCO2 22.6,PO2 98.2,HCO3 14.3,St.HCO3 17.6,BEB -8.5,BEecf -

9.4,TCO2 29.4,O2 Sat 97.8,O2 Count 14.3

LIVER FUNCTION TEST (LFT) 05-06-2025 Total Bilurubin 2.04 mg/dl,Direct Bilurubin 0.45 mg/dl

,SGOT(AST) 22 IU/L ,SGPT(ALT) 10 IU/L,ALKALINE PHOSPHATASE 246 IU/L ,TOTAL PROTEINS

7.1 gm/dl ,ALBUMIN 4.1 gm/dl ,A/G RATIO 1.37SERUM ELECTROLYTES (Na, K, C l) 05-06-

2025,SODIUM 138 mmol/L ,POTASSIUM 3.8 mmol/L ,CHLORIDE 105 mmol/L

HEMOGRAM ON 5-06-2025: HAEMOGLOBIN 11.6 gm/dl , TOTAL COUNT 10,200 cells/cumm,

NEUTROPHILS 76 % , LYMPHOCYTES 15 % ,EOSINDOPHILS 04 %, MONOCYTES 5 % ,

BASOPHILS 00 % , PCV 35.2 vol % , M C V 91.5 fl , M C H 30.2 pg, M C H C 33.1 %, RDW-CV 15.8

% , RDW-S 53 fl, RBC COUNT 3.84 millions/cumm, PLATELET COUNT 2.49 lakhs/cu.mm SMEAR:

RBC Normocytic normochromic, WBC normal, PLATELETS Adeqaute , No hemoparasites seen,

IMPRESSION Normocytic normochromic blood picture

MRI BRAIN ON 5/6/25: ACUTE INFARCT IN RIGHT FRONYOTEMPORAL AND RIGHT PARIETAL

LOBES-MCA INFARCTTROPONIN-I ON 6/6/25:-11.1pg/mlHbA1c DONE ON 7/6/25:- 7.6%

COMPLETE URINE EXAMINATION (CUE) 07-06-2025 COLOUR REDDISH,APPEARANCE

Clear,REACTION Acidic,SP.GRAVITY 1.010,ALBUMIN ++++,SUGAR +,BILE SALTS Nil,BILE

PIGMENTS Nil,PUS CELLS 10-11,EPITHELIAL CELLS 4-5,RED BLOOD CELLS

PLENTY,CRYSTALS Nil,CASTS Nil,AMORPHOUS DEPOSITS Absent,OTHERS Nil

RFT 07-06-2025 ,UREA 52 mg/dl ,CREATININE 0.9 mg/dl ,URIC ACID 3.5 mmol/L ,CALCIUM 9.8

mg/dl ,PHOSPHOROUS 4.6 mg/dl ,SODIUM 142 mmol/L,POTASSIUM 3.8 mmol/L,CHLORIDE 105

mmol/LCOMPLETE URINE EXAMINATION (CUE) 07-06-2025 COLOUR PALE

YELLOW,APPEARANCE Clear,REACTION Acidic,SP.GRAVITY 1.010,ALBUMIN +++,SUGAR

+,BILE SALTS Nil,BILE PIGMENTS Nil,PUS CELLS 4-5,EPITHELIAL CELLS 2-4,RED BLOOD

CELLS NIL,CRYSTALS Nil,CASTS Nil,AMORPHOUS DEPOSITS Absent,OTHERS NilON 7/6/25:-

SPOT URINEPROTEIN27mg/dl.SPOTURINECREATININE187.8mg/dl.RATIO0.14

HEMOGRAM ON 7-06-2025: HAEMOGLOBIN 11.6 gm/dl , TOTAL COUNT 15,000 cells/cumm,

NEUTROPHILS 77 % , LYMPHOCYTES 13 % ,EOSINOPHILS 01 %, MONOCYTES 09 % ,

BASOPHILS 00 % , PCV 37.9 vol % , M C V 86.1 fl , M C H 30.9 pg, M C H C 35.9 %, RDW-CV 14.8

% , RDW-SD 48.2 fl, RBC COUNT 4.4 millions/cumm, PLATELET COUNT 2.45 lakhs/cu.mm

SMEAR: RBC Normocytic normochromic, WBC normal, PLATELETS Adeqaute , No hemoparasites

seen, IMPRESSION Normocytic normochromic blood picture

COMPLETE URINE EXAMINATION (CUE) 08-06-2025 COLOUR Pale yellow,APPEARANCE

Clear,REACTION Acidic,SP.GRAVITY 1.010,ALBUMIN ++,SUGAR +,BILE SALTS Nil,BILE

PIGMENTS Nil,PUS CELLS 5-6,EPITHELIAL CELLS 2-4,RED BLOOD CELLS Nil,CRYSTALS

Nil,CASTS Nil,AMORPHOUS DEPOSITS Absent,OTHERS Nil

SERUM ELECTROLYTES ON 10/6/25:-SODIUM 142 mmol/L,POTASSIUM 3.5 mmol/L,CHLORIDE

104 mmol/L,CALCIUM IONIZED 1.06 mmol/LTROPONIN-I ON 8/6/25:-23.4pg/ml

HEMOGRAM ON 8-06-2025: HAEMOGLOBIN 12.1 gm/dl , TOTAL COUNT 12,900 cells/cumm,

NEUTROPHILS 73 % , LYMPHOCYTES 17 % ,EOSINOPHILS 01 %, MONOCYTES 09 % ,

BASOPHILS 00 % , PCV 34.7 vol % , M C V 86.8 fl , M C H 30.3 pg, M C H C 34.9 %, RDW-CV 15 %

, RDW-SD 48.3 fl, RBC COUNT 4 millions/cumm, PLATELET COUNT 2.12 lakhs/cu.mm SMEAR:

RBC Normocytic normochromic, WBC normal, PLATELETS Adeqaute , No hemoparasites seen,

IMPRESSION Normocytic normochromic blood picture

HEMOGRAM ON 9-06-2025: HAEMOGLOBIN 12.4 gm/dl , TOTAL COUNT 12,300 cells/cumm,

NEUTROPHILS 76 % , LYMPHOCYTES 15 % ,EOSINOPHILS 01 %, MONOCYTES 08 % ,

BASOPHILS 00 % , PCV 37.5 vol % , M C V 93.8 fl , M C H 31 pg, M C H C 33 %, RDW-CV 15 % ,

RDW-SD 51 fl, RBC COUNT 4 millions/cumm, PLATELET COUNT 1.93 lakhs/cu.mm SMEAR: RBC

Normocytic normochromic, WBC normal, PLATELETS Adeqaute , No hemoparasites seen,

IMPRESSION Normocytic normochromic blood picture

RFT 09-06-2025 ,UREA 109 mg/dl ,CREATININE 1.0 mg/dl ,URIC ACID 4.2 mmol/L ,CALCIUM 10.0

mg/dl ,PHOSPHOROUS 4.68 mg/dl ,SODIUM 142 mmol/L,POTASSIUM 3.68 mmol/L,CHLORIDE

104 mmol/L

2D ECHO WAS DONE ON 9/6/25: IMPRESSION- EF: 52%, SINUS ARRHYTHMIA, CALCIFIED AV,

GRADE I DIASTOLIC DYSFUNCTION, FAIR LV SYSTOLIC FUNCTION

BLOOD, URINE, CSF CULTURE AND SENSITIVITY ON 9/6/25: NO BACTERIAL GROWTH

MRI BRAIN WAS DONE ON 9/6/25:- LARGE ACUTE INFARCT IN RIGHT FRONTAL AND

PARIETAL LOBES INVOLVING BOTH GRAY AND WHITE MATTER AND RIGHT LENTIFORM

NUCLEUS-MCA TERRITORY INFARCT

RFT 09-06-2025 ,UREA 89 mg/dl ,CREATININE 0.9 mg/dl ,URIC ACID 4.0 mmol/L ,CALCIUM 10.0

mg/dl ,PHOSPHOROUS 3.77 mg/dl ,SODIUM 143 mmol/L,POTASSIUM 3.3 mmol/L,CHLORIDE 102

mmol/L

HEMOGRAM ON 10-06-2025: HAEMOGLOBIN 12.4 gm/dl , TOTAL COUNT 12,600 cells/cumm,

NEUTROPHILS 78 % , LYMPHOCYTES 15 % ,EOSINOPHILS 01 %, MONOCYTES 06 % ,

BASOPHILS 00 % , PCV 38.2 vol % , M C V 94.6 fl , M C H 30.6 pg, M C H C 32.4 %, RDW-CV 15.2

% , RDW-SD 51.8 fl, RBC COUNT 4 millions/cumm, PLATELET COUNT 1.9 lakhs/cu.mm SMEAR:

RBC Normocytic normochromic, WBC normal, PLATELETS Adeqaute , No hemoparasites seen,

IMPRESSION Normocytic normochromic blood picture

SERUM ELECTROLYTES ON 10/6/25:-SODIUM 142 mmol/L,POTASSIUM 3.5 mmol/L,CHLORIDE

104 mmol/L,CALCIUM IONIZED 1.06 mmol/L

ABG 10/6/25:-PH 7.37 PCO2 33.7 mmHg O2 90.0 mmHg HCO3 19.3 mmol/LSt.HCO3 20.5

mmol/LBEB -4.7 mmol/LBEecf -5.0 mmol/LTCO2 39.5 VOLO2 Sat 96.7 %O2 Count 15.6 vol %

MALARIALPARASITE ON 10/6/25:-Negative (-ve)

PERIPHERALSMEAR ON 10/6/25:-RBC : Normocytic normochromicWBC : increased count on

smearPLATELET : Adequateimp ; Normocytic normochromic with leukocytosis

CHEST X RAY ON 10/6/25:- FEW ILL DEFINED HOMOGENOUS LINEAR OPACITIES IN UPPER

AND LOWER LOBES OF RIGHT LUNG AND IN UPPER LOBE OF LEFT LUNG

TRUENAT MTB 10/6/25:- NOT DETECTED

ABG 11/6/25:- PH 7.43 PCO2 31.5 mmHg PO2 50.3 mmHg HCO3 20.7 mmol/LSt.HCO3 22.2

mmol/LBEB -2.4 mmol/LBEecf -2.9 mmol/LTCO2 41.9 VOLO2 Sat 85.4 %O2 Count 13.9 vol %

HEMOGRAM 11/6/25:-HAEMOGLOBIN 12.1 gm/dl TOTAL COUNT 13,000

cells/cummNEUTROPHILS 72 % LYMPHOCYTES 21 % EOSINOPHILS 01 % MONOCYTES 06

%BASOPHILS 00 %PCV 36.8 vol %M C V 94.0 fl M C H 30.9 pg M C H C 32.9 %RDW-CV 15.0

%RDW-SD 50.8 fl RBC COUNT 3.92 millions/cumm PLATELET COUNT 1.98 lakhs/cu.mm

SMEARRBC Normocytic normochromicWBC With in normal limits PLATELETS Adeqaute

HEMOPARASITES No hemoparasites seenIMPRESSION Normocytic normochromic bloodpicture

with leukocytosisURINE, BLOOD CULTURE AND SENSITIVITY: NO GROWTH

RFT 11/6/25:-UREA 62 mg/dl CREATININE 0.8 mg/dl URIC ACID 3.0 mmol/L CALCIUM 10.1 mg/dl

PHOSPHOROUS 2.69 mg/dl SODIUM 139 mmol/L POTASSIUM 4.5 mmol/L.

11/6/25:

APTT TEST 38 Sec,D-DIMER 3230 ng/ml,Prothrombin Time 20 Sec,INR 1.4

12/6/25:-

HEMOGRAM: HAEMOGLOBIN 11.9 gm/dl TOTAL COUNT 13,700 cells/cummNEUTROPHILS 78 %

LYMPHOCYTES 15 %EOSINOPHILS 01 %MONOCYTES 06 %BASOPHILS 00 %PCV 36.7 vol %M

C V 92.7 fl M C H 30.1 pg M C H C 32.5 %RDW-CV 14.9 %RDW-SD 50.1 fl RBC COUNT 3.96

millions/cumm PLATELET COUNT 1.89 lakhs/cu.mmSMEARRBC Normocytic normochromic WBC

increased count on smearPLATELETS Adeqaute HEMOPARASITES No hemoparasites

seenIMPRESSION Normocytic normochromic withleukocytosis

SERUM ELECTROLYTES (Na, K, C l)SODIUM 136 mmol/L POTASSIUM 3.5 mmol/L CHLORIDE

104 mmol/LCALCIUM IONIZED 1.09 mmol/L

13/6/25:-

HEMOGRAM:HAEMOGLOBIN 11.5 gm/dl TOTAL COUNT 10,000 cells/cummNEUTROPHILS 75 %

LYMPHOCYTES 13 %EOSINOPHILS 02 %MONOCYTES 10 %BASOPHILS 00 %PCV 32.6 vol % M

C V 86.2 fl M C H 30.4 pg M C H C 35.3 %RDW-CV 14.0 %RDW-SD 45.1 fl RBC COUNT 3.78

millions/cumm PLATELET COUNT 2.12 lakhs/cu.mmSMEARRBC Normocytic normochromicWBC

With in normal limits PLATELETS Adequate in number and distributionHEMOPARASITES No

hemoparasites seenIMPRESSION Normocytic normochromic bloodpicture

RFT:UREA 52 mg/dl CREATININE 0.8 mg/dlURIC ACID 2.0 mmol/L CALCIUM 9.2 mg/dl

PHOSPHOROUS 2.7 mg/dl SODIUM 135 mmol/LPOTASSIUM 3.5 mmol/L.CHLORIDE 101 mmol/L

98 - 107

Treatment Given(Enter only Generic Name)

 OXYGEN SUPPLEMENTATION WITH 4LITRES OXYFGEN

RT FEEDS 75ML MILK WITH 2 SCOOPS OF PROTEIN POWDER 4 HRLY

RT FEEDS 100 ML WATER HRLY

IVF 0.9%NS AT 75 ML/HR

INJ MONOCEF 2 GM IV/BD

INJ.AGUMENTIN 1.2GM IV/BD

INJ VANCOMYCIN 1.2 GM IV/TID

INJ FALCIGO 120MG IV 0-12-24

INJ.PAN 40MG IV/OD

INJ CLINDAMYCIN 600 MG IV/BD

INJ ENOXAPARIN-60 S/C OD

INJ.HAI S/C TID ACCORDING TO GRBS

INJ.NEOMOL 1GM IV/SOS(IF TEMPERATURE >101F)

INJ VIT K 10 MG/ML IM/OD(DEEP IM)

TAB.DOLO 650MG RT/TID

TAB.ECOSPIRIN-GOLD (75-75-20)RT/HS

TAB.STROCIT PLUS RT/OD

TAB.TELMA 20MG RT/OD

TAB BISOPROLOL 2.5 MG RT/BD

TAB FLUCONAZOLE 150MG RT/OD

TAB GABAPENTIN 150MG RT/HS

TAB OSELTAMAVIR 75 MG RT/BD

TAB.METFORMIN 500MG RT/OD

TAB LARIGO DS KIT RT/OD

NEOSPORIN POWDER FOR L/A

GRBS 7 POINT MONITORING

TEMPERATURE CHARTING 4 TH HOURLY

POSITION CHANGE 2ND HOURLY

REGULAR PHYSIOTHERAPY OF LEFT UPPER AND LOWER LIMBS

Advice at Discharge

RT FEEDS 75ML MILK WITH 2 SCOOPS OF PROTEIN POWDER 4 HRLY

RT FEEDS 100 ML WATER HRLY

INJ HAI SC/TID 6UNITS-6UNITS-6UNITS

TAB TAXIM O 200 MG RT/BD X 5 DAYS

TAB FLUCONAZOLE 150MG RT/OD X 5 DAYS

TAB CLINDAMYCIN 300 MG RT/BD X 5 DAYS

TAB LARIGO DS KIT RT/OD X 2DAYS

TAB.PAN 40MG RT/OD X 5 DAYS

TAB.ECOSPIRIN-GOLD (75-75-20)RT/HS TO BE CONTINUED

TAB.METFORMIN 500MG RT/OD TO BE CONTINUED

TAB.TELMA 40MG RT/OD TO BE CONTINUED

TAB BISOPROLOL 2.5 MG RT/BD X 2 WEEKS

TAB.STROCIT PLUS RT/OD X 2 WEEKS

TAB GABAPENTIN 150MG RT/HS X 1 MONTH

TAB.DOLO 650MG RT/SOS

ASEPTIC REGULAR DRESSING OF BED SORE WITH NEOSPORIN POWDER FOR L/A

REGULAR PHYSIOTHERAPY OF LEFT UPPER AND LOWER LIMBS

POSITION CHANGE 2ND HOURLY

Follow Up

FOLLOW UP TO GENERAL MEDICINE OPD AFTER 2 WEEKS/SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 29

80years/MALE

D. O. A : 28/05/2025

D. O. D : 02/06/2025

Diagnosis

REFRACTORY CARDIOGENIC SHOCK WITH ACUTE CARDIOGENIC PULMONARY EDEMA

ACUTE ISCHEMIC STROKE (INFARCT IN RIGHT CORONA RADIATA EXTENDING TO BASAL

GANGLIA) WITH ? NON CONVULSIVE STATUS EPILEPTICUS

PAROXYSMAL ATRIAL FIBRILLATION WITH FVR (REVERTED)

HEART FAILURE WITH REDUCED EJECTION FRACTION

ACTUE ON CHRONIC KIDNEY DISEASE

K/C/O HYPERTENSION

Case History and Clinical Findings

C/O LOC SINCE TODAY AFTERNOON FOR 2 HOURS

HOPI:

PATIENT WAS ASYPMTOPMATIC 1 DAY AGO THEN HAD HISTORY OF SLIP AND FALL ON

STAIR CASE THAT LED TO TRAUMA TO LEFT SHOULDER AND LEFT HIP.SINCE TODAY

ATERNOON PATIENT BECAME UNRESPONSIVE SUDDEN IN ONSET WITH NO INVOULNTARY

MOVEMENTS ,UPROLLING OF EYES , FROTH FROM MOUTH ,NO TONGUE BITE

,UNRESPONSIVENESS LASTED FOR 2 HOURS .H/O INVOULNTARY MICTURITION (+) WHILE

SHIFTING TO HOSPITAL

H/O 1 EPISODE OF VOMITING

H/O SLURRING OF SPEECH SINCE THEN

H/O REDUCED FOOD INTAKE SINCE TODAY MORNING

NO H/O FEVER , HEADACHE BLURRING OF VISION

NO H/O NECK STIFFNESS , GIDDINES ,SYNCOPL ATTACKS

NO H/O REDUCED URINE OUTPUT ,PEDAL EDEMA

PAST HISTORY:

K/C/O HTN SINCE 4 YEARS ON TAB.ATENOLOL 50MG PO/OD

N/K/C/C DM,CVA,CAD,THYROID ,TB ,SEIZURE,ASTHMA

PERSONAL HISTORY:

APPETITE -REDUCED

BOWELS- REGULAR

BLADDER-REGULAR

SLEEP- ADEQUATE

NO ALLERGIES

ADDICTIONS-OCCASIONBAL ALCOHOLIC SINCE 40 YEARS

SMOKING 1 PACK PER DAY SINCE 40 YEARS

GENERAL EXAMINATION:

PATIENT IS C/C/C

TEMPERATURE - 98F

BP - 110/70 MMHG

PR - 74 BPM

RR - 18CPM

SPO2 -68% ON ROOM AIR

90% 4 LITRES OF OXYGEN

GRBS: 145 MG/DL

SYSTEMIC EXAMINATION:-

P/A - SOFT NON TENDER

CVS- S1 ,S2 HEARD, NO MURMURS

RS-BAE PRESENT ,B/L DIFFUSE COARSE CREPTS PRESENT

CNS : PATIENT CONSCIOUS AT PRESENTATION

 RT LT

TONE

UL REDUCED REDUCED

LL REDUCED REDUCED

POWER

UL COULD NOT BE ELICITED

LL COULD NOT BE ELICITED

REFLEXES

BICEPS +2 +2

TRICEPS +2 +2

KNEE +1 +1

ANKLE +1 +1

PLANTAR EXTENSION EXTENSION

Investigation

ABG 28-05-2025 09:23:PM

PH 7.35PCO2 25.0PO2 35.2HCO3 13.4St.HCO3 15.6O2 Sat 60.4

RFT 28-05-2025 10:38:PM

UREA 94 mg/dl 50-17 mg/dlCREATININE 2.1 mg/dl 1.3-0.8 mg/dlURIC ACID 4.8 mmol/L 7.2-3.5

mmol/LCALCIUM 9.5 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 4.0 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 101 mmol/L 98-107

mmol/L

LIVER FUNCTION TEST (LFT) 28-05-2025 10:38:PMTotal Bilurubin 2.97 mg/dl 1-0 mg/dlDirect

Bilurubin 0.76 mg/dl 0.2-0.0 mg/dlSGOT(AST) 22 IU/L 35-0 IU/LSGPT(ALT) 11 IU/L 45-0

IU/LALKALINE PHOSPHATASE 122 IU/L 128-56 IU/LTOTAL PROTEINS 5.7 gm/dl 8.3-6.4

gm/dlALBUMIN 3.55 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.65

HBsAg-RAPID 28-05-2025 10:38:PM NegativeAnti HCV Antibodies - RAPID 28-05-2025 10:38:PM

Non Reactive

COMPLETE URINE EXAMINATION (CUE) 28-05-2025 10:38:PMCOLOUR Pale

yellowAPPEARANCE CloudyREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 1-2EPITHELIAL CELLS 0-2RED BLOOD CELLS

PlentyCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

ABG 29-05-2025 07:36:AMPH 7.30PCO2 25.4PO2 94.7HCO3 12.2St.HCO3 15.0BEB -12.5BEecf -

13.0TCO2 24.4O2 Sat 96.6

RFT 30-05-2025 09:09:AMUREA 133 mg/dl 50-17 mg/dlCREATININE 2.1 mg/dl 1.3-0.8 mg/dlURIC

ACID 5.3 mmol/L 7.2-3.5 mmol/LCALCIUM 7.8 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.5 mg/dl 4.5-

2.5 mg/dlSODIUM 140 mmol/L 145-136 mmol/LPOTASSIUM 3.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

100 mmol/L 98-107 mmol/LCOMPLETE URINE EXAMINATION (CUE) 30-05-2025

09:09:AMCOLOUR Pale yellowAPPEARANCE CloudyREACTION AcidicSP.GRAVITY

1.010ALBUMIN +SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 1-2EPITHELIAL

CELLS 0-2RED BLOOD CELLS PlentyCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS

AbsentOTHERS Nil

RFT 30-05-2025 09:23:AMUREA 161 mg/dl 50-17 mg/dlCREATININE 2.1 mg/dl 1.3-0.8 mg/dlURIC

ACID 6.5 mmol/L 7.2-3.5 mmol/LCALCIUM 9.9 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.1 mg/dl 4.5-

2.5 mg/dlSODIUM 143 mmol/L 145-136 mmol/LPOTASSIUM 3.7 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

106 mmol/L 98-107 mmol/LCOMPLETE URINE EXAMINATION (CUE) 30-05-2025

09:23:AMCOLOUR ReddishAPPEARANCE CloudyREACTION AcidicSP.GRAVITY 1.010ALBUMIN

+SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 4-6EPITHELIAL CELLS 2-3RED

BLOOD CELLS PlentyCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

ABG 31-05-2025 06:55:AMPH 7.34PCO2 30.1PO2 60.8HCO3 15.9St.HCO3 17.7BEB -8.2BEecf -

8.7TCO2 31.8O2 Sat 88.8O2 Count 17.5RFT 31-05-2025 11:00:PMUREA 144 mg/dl 50-17

mg/dlCREATININE 1.7 mg/dl 1.3-0.8 mg/dlURIC ACID 6.5 mmol/L 7.2-3.5 mmol/LCALCIUM 9.9

mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.5 mg/dl 4.5-2.5 mg/dlSODIUM 142 mmol/L 145-136

mmol/LPOTASSIUM 3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 106 mmol/L 98-107 mmol/L

HEMOGRAM 28/5/2025

HEMOGRAM(29/5/25):

HB-14.4GM/DL

TLC-19000

PCV-42.1

RBC COUNT-3.67MILLIONS/CUMM

PLATELET COUNT-1.20 LAKH /CUMM

HEMOGRAM(30/5 /25):

HB-11 GM/DL

TLC-14200

PCV-30.2

RBC COUNT-2.79 MILLIONS/CUMM

PLATELET COUNT-80000/CUMM

HEMOGRAM(31/5/25):

HB-13.1GM/DL

TLC-15200

PCV-38.3

RBC COUNT-3.36 MILLIONS/CUMM

PLATELET COUNT-82000/CUMM

HEMOGRAM(1/6/25):

HB-14.1GM/DL

TLC-14000

PCV-40.8

RBC COUNT-3.67 MILLIONS/CUMM

PLATELET COUNT-80000/CUMM

PLAIN MRI SCAN OF BRAIN (28/5/25)-IMPRESSION:

-SMALL ACUTE INFARCT MEASURING APPROXIMATELY 14MM IN THE RIGHT CORONA

RADIATA WITH SUBTLE EXTENSION INTO RIGHT BASAL GANGLIA

-MULTIPLE CONFLUENT AND FEW DISCRETE FLAIR HYPER INTENSITIES ARE SEEN

INVOLVING BILATERAL FRONTOPARIETAL PERI VENTRICULAR AND DEEP WHITE MATTER

WITHOUT DIFFUSION RESTRICTION-S/O LEUKOARAISIS

-FEW CHRONIC LACUNAR INFARCTS IN BILATERAL BASAL GANGLIA AND THALAMI

-FEW CHRONIC MICRO HEMORRHAGES IN BILATRAL TEMPORAL LOBE DEEP WHITE

MATTER

-MODERATE DIFFUSE CEREBRAL ATROPHY WITH PROMINENT SUPRATENTORIUAL

VENTRICULAR SYSTEM

-BILATREAL MILD HIPPOCAMPAL ATROPHY CORRESPONDING TO CEREBRAL

ATROPHY.NROMAL HIPPOCAMPAL SURFACE DIGITATIONS ARE MAINTAINED

-THE POSTERIOPR FOSSA SHOWS NORMAL CEREBELLUM.BOTH THE C.P ANGLES ARE

CLEAR

-THE MEDULLA,PONS AND MIDBRAIN SHOW NORMAL SIGNAL INSTENSITY .BASAL

CISTERNS ARE NORMAL

-THE PITUTARY GLAND AND OPTIC CHIASM APPEAR NORMAL

-VISUALIZED PARANASAL SINUSES AND BOTH ORBITS APPEAR GROSSLY NORMAL

2D ECHO - 29/5/25- IMPRESSION:

MILD GLOBAL HYPOKINESIA, MILD LVH+

MODERATE TR+ WITH PAH (RVSP 49+10=59MMHG)

MILD AR+ ,TRIVIAL MR+,MILD PR+

SCLROTIC AV NO AS/MS

IAS INTACT /ANEURYSM

EF=54% FAIR LV SYSTOLIC FUNCTION

GRADE 1 DIASTOLIC DYSFUNCTION

NO PE, NO LV CLOT

DILATED RA/RV/IVC

MILD DILATED MPA(2.4CM)

IVC SIZE 1.55CM NOT COLLAPSING

2D ECHO-31/5/25 REVIEW:

MILD GLOBAL HYPOKINESIA

MILD CONCENTRIC LVH+ AND RVH+

MODERATE TO SEVERE TR+ WITH PAH (RVSP 54+10=64MMHG)

TRIVIAL AR+ ,TRIVIAL MR+,MILD PR+

SCLROTIC AV NO AS/MS

IAS INTACT /ANEURYSM

EF=52% FAIR LV SYSTOLIC FUNCTION

GRADE 1 DIASTOLIC DYSFUNCTION

NO PE, NO LV CLOT

IVC SIZE 0.9CM AND COLLAPSING

DILATED RA/RV

Treatment Given(Enter only Generic Name)

RT FEEDS 50ML WATER EVERY SECOND HOURLY,200ML MILK EVERY 4TH HOURLY

IV NS,DNS AT THE RATE 50ML/HR

INJ.MONOCEF 1GM IV/BD FOR 3 DAYS

INJ.MEROPENEM 500MG IV/BD FOR 2 DAYS

INJ.CLINDAMYCIN 600MG IV/TID FOR 2 DAYS

IINJ.SODIUM VALPROATE 500MG IV/BD

INJ.LEVIPIL 500MG IV/BD

INJ.PIRACETAM 400MG IV/TID

INJ.CITICHOLINE 500MG IV/BD

INJ.DOBUTAMINE 1AMP IN 45ML NS @5 ML/HR TO MAINATIN MAP >65MMHG

INJ.MIDAZ (30MG) 30ML+FENTANYL 4ML(200MG) IN 16 ML NS AT THE RATE 4ML/HR

INJ.NORADRENALINE 2AMP (8MG) IN 46 ML NS @ 5ML/HR 1MCG/KG/MIN

INJ VASOPRESSIN 2 AMP IN @2.4 ML/HR

INJ.OPTINEURON 1 AMP IN 100ML NS IV/OD

INJ.LASIX 40MG IV/BD

INJ.THIAMINE 200MG IV/BD

INJ.PAN 40MG IV/OD

INJ.NEOMOL 1AMP IV SOS

INJ.CALCIUM GLUCONATE 10CC IN 100ML NS IV OVER 10 MINUTES

INJ.METOPROLOL 1MG IV STAT

INJ.AMIODARONE 150MG IN 100ML NS IV STAT

NEB.BUDECORT,MUCOMISI 4TH HOURLY

TAB.MET XL 25MG RT /OD

TAB.ECOSPRIN -AV RT 75/10 OD/HS(0-0-1)

TAB.NEFROSAVE BD(1-0-1)

TAB.BROMOCRIPTINE 2.5MG RT/TID(1-1-1)

TAB.DERIDHYLLINE 100MG RT/BD (1-0-1)

TAB.MONTEK.AB RT/BD(1-0-1)

Follow Up

DEATH SUMMARY: 80 YEAR OLD MALE WAS BROUGHT WITH COMPLAINTS OF SUDDEN

ONSET OF LOSS OF CONSCIOUSNESS FOR 2 HOURS ON THE DAY OF ADMISSION. WITH

HISTORY OF SLIP AND FALL 1 DAY AGO VITALS AT DAY OF ADMISSION GCS E4V5M6

TEMP:98F, PR:74BPM RR:18CPM, SPO2:68% ON ROOM AIR ,90% ON 4 LIT OXYGEN . ON

AUSCULTATION B/L DIFFUSE COARSE CREPTS PRESENT , MRI BRAIN AND ALL OTHER

NECESSARY INVESTIGATIONS WERE SENT AND PATIENT WAS SHIFTED TO ICU WITH

OXYGEN SUPPORT MRI BRAIN:ACUTE INFRACTS, IN RIGHT CORONA RADIATA EXTENDING

INTO BASAL GANGLIA, INVESTIGATIONS REVEALED DERANGED RFT,LFT,RAISED TLC ,

CONSIDERING THE CLINICAL PICTURE AS SEIZURES 2° TO AIS TREATMENT WAS STARTED

WITH ANTIEPILEPTICS, ANTIBIOTICS AND OTHER SUPPORTIVE TREATMENT 2DECHO

REVELEAD DILATED RA RV. BY NEXT DAY MORNING SENSORIUM DETORIATED TO

GCS:E2V2M3 ABG DONE - PH:7.3, PCO2:25.4, PO2:94.7 HCO3:12.2 VITALS WERE STABLE .

TREATMENT WAS CONTINUED AND PATIENT WAS MONITORED CONTINOUSLY PATIENT

WAS STARTED ON ANOTHER ANTIEPILEPTICS I/V/O NO IMPROVEMENT IN SENSORIUM . ON

DAY 4 PATIENT HAD ATRIAL FIBRILLATION WITH FVR IMMEDIATE TREATMENT WITH

AMIODARONE STAT DOSE FOLLOWED BY AMIODARONE INFUSION STARTED

,SIMULTANEOUSLY LOW DOSE DOBUTAMINE INFUSION WAS STARTED I/V/O HEART

FAILURE AND CONTINUED .ON SAME DAY NIGHT PATIENT HAD SUDDEN FALL IN

SATURATION IMPROVED WITH DIURETICS AND INJ HYDROCORT STAT DOSE. FEVER

SPIKES PRESENT FROM DAY 4 AND ELEVATED TOTAL COUNT SO ANTIBIOTICS WERE

ESCALATED TO INJ.MEROPENEM AND INJ.CLINDAMYCIN, ACCORDING TO CREATININE

CLEARANCE ,ORAL ANTIARRHYTHMIC AND ANTICOAGULANTS WERE STARTED ON DAY 5

TRIPLE LUMEN CATHETERIZATION WAS DONE FOR DRUG ADMISSION LATER THEIR WAS

SUDDEN DROP IN SATURATION ON DAY 5 EVENING SPO2:50 % ON ASCULTATION DIFFUSE

COARSE CREPTS PRESENT PATIENT WAS INTUBATED ON DAY 5 I/V/O TYPE 1

RESPIRATORY FAILURE SECONDARY TO CARDIOGENIC PULMONARY EDEMA AND

CONNECTED TO MECHANICAL VENTILATOR WITH ACMV MODE FIO2:100% Vt:380, PEEP:5

VITALS POST INTUBATION BP:60/40MMHG , PR:120BPM SPO2:78%,

STARTED ON INJ NORAD INFUSION @0.15MCG /KG/MIN AND TITRATED ACCORDING TO

MAP>65MG/DL, STARTES ON SEDATION AND PARALYTICS .WITH NO IMPROVEMENT

FURTHER STARTED ON 3RD INOTROPIC SUPPORT INJ VASOPRESSIN INFUSION AND

MONITORED REGULARLY .AT AROUND 7:40 AM SATURATIONS WERE DROPPED ,

BRADYCARDIA DEVELOPED ,CENTRAL PULSES WERE NOT FELT SO IMMEDIATE CPR WAS

STARTED ACCORDINGLY TO LATEST ACLS GUIDELINES,BUT INSPITE OF ABOVE

RESUSCITATIVE EFFORTS PATINET COULDN'T BE REVIVED AND DECLARED DEAD AT

8:21AM ON 2/6/25

IMMEDIATE CAUSE

REFRACTORY CARDIOGENIC SHOCK WITH ACUTE CARDIOGENIC PULMONARY EDEMA

ACUTE ISCHEMIC STROKE WITH ?NON CONVULSIVE STATUS EPILEPTICUS WITH

ASPIRATION PNEUMONIA

ANTECEDENT CAUSE

PAROXYSMAL ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE

HEART FAILURE WITH REDUCED EJECTION FRACTION

ACUTE ON CHRONIC KIDNEY DISEASE

K/C/O HYPERTENSION

Death Date

Date:2/6/25.

CASE NO : 30

90years/FEMALE

D. O. A : 13/05/2025

D. O. D : 22/05/2025

Diagnosis

CVA- ACUTE ISCHEMIC STROKE LEFT SIDED HEMIPARESIS WITH

[RIGHT PCA (P2)INFARCT WITH TEMPORO OCCIPITAL THALAMO CAPSULAR INFARCT]

PAROXYSMAL AF WITH CVR

K/C/O HYPERTENSION

K/C/OTYPE 2 DM

Case History and Clinical Findings

PATIENT BROUGHT TO THE CASUALITY WITH C/O WEAKNESS OF LEFT UPPER AND LOWER

LIMBS SINCE 4 DAYS

HOPI:PATIENT WAS APPARENTLY NORMAL 4 DAYS BACK SHE THEN HAD AN EPISODE OF

LOSS OF CONSCIOUSNESS/ALTERED STATE FOR A PERIOD OF 1-2 MINS AND REGAINED

ALERTNESS BY HERSELF.SHE WAS NOT HAVING WEAKNESS AT THAT TIME.

NEXT DAY MORNING PATIENT ATTENDERS OBSERVED WEAKNESS OF LEFT UPPER AND

LOWER LIMBS WITH INVOLUNTARY MICTURITION AND DEFECATION ASSOCIATED WITH

DEVIATION OF MOUTH TO LEFT SIDE,DROOLING OF SALIVA , PT WENT TO AN OUTSIDE

HOSPITAL AND WAS MANAGED THERE, CAME TO US FOR FURTHER MANAGEMENT

PATIENT HAS NO DIFFICULTY IN SWALLOWING UNTIL YESTERDAY MORNING AND SHE HAD

DIFFICULTY IN SWALLOWING SINCE THEN

NO C/O VOMITINGS,DYSARTHRIA,INVOLUNTARY MOVEMENTS

HISTORY OF PAST ILLNESS:

K/C/O TYPE 2 DIABETES MELLITUS-ON TAB.METFORMIN 500 MG OD

K/C/O HYPERTENSION ON TAB.TELMA 40MG OD

N/K/C/O TB,EPILEPSY,CVA,CAD,THYROID DISORDERS,BRONCHIAL ASTHMA

PERSONAL HISTORY:

DIET: MIXED

APPETITE: NORMAL

SLEEP: ADEQUATE

BOWEL AND BLADDER : REGULAR

GENERAL EAMINATION:

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA

ON ADMISSION

BP:140/100MMHG

PR:80 PM

RR:16CPMB

SPO2:94%RA

GRBS: 133 MG/DL

SYSTEMIC EXAMINATION:

CVS:S1 S2 HEARD ,NO MURMURS

RS:BAE PRESENT NVBS PRESENT NO ADDED SOUNDS

PA:SOFT,NON TENDER

CNS:

GCS:E3 V5 M6

PUPILS:NSRL

HMF -CONSCIOUS,ORIENTED

 TONE UL N DECREASED

 LL N DECREASED

 POWER

 UL 4/5 2/5

 LL 4/5 2/5

 BICEPS TRICEPS SUPINATOR KNEE ANKLE PLANTAR

 RIGHT - - - - - FLEXOR

 LEFT - - - - - EXTENSOR

AT DISCHARGE

BP:140/90MMHG

PR:60 BPM

RR:22CPM

SPO2:96%RA

SYSTEMIC EXAMINATION:

CVS:S1 S2 HEARD ,NO MURMURS

RS:BAE PRESENT NVBS PRESENT NO ADDED SOUNDS

PA:SOFT,NON TENDER

CNS:

GCS:E4V5 M6

PUPILS:NSRL

HMF -CONSCIOUS,ORIENTED

 R L

 TONE UL N N

 LL N N

 POWER

 UL 5/5 3/5

 LL 5/5 4/5

 BICEPS TRICEPS SUPINATOR KNEE ANKLE PLANTAR

 RIGHT +2 +2 - - - FLEXOR

 LEFT +2 - - - - EXTENSOR

COURSE IN HOSPITAL-

90/F PRESENTED TO CASUALITY WITH LEFT UPPER AND LOWER LIMBS WEAKNESS SINCE 4

DAYS , ON PRESENTATION PT WAS CONSCIOUS AND ORIENTED WITH GCS-E3V5M6

,PUPILS-NSRL,PR-80BPM,RR-16CPM,BP-140/100 MM/HG,SPO2-94% ON RA, DIAGNOSED AS

CVA- ACUTE ISCHEMIC STROKE LEFT SIDED HEMIPARESIS WITH [RIGHT PCA (P2)INFARCT

WITH TEMPORO OCCIPITAL THALAMO CAPSULAR INFARCT], PAROXYSMAL AF WITH CVR

WAS STARTED ON DUAL ANTIPLATLETS, STATINS, ANTICOAGULANTS, RYLES FEEDS, AND

LEFT UL AND LL PHYSIOTHERAPY. PATIENT MOTOR POWER IS IMPROVED.ON DAY 6 OF

ADDMISSION BP SPIKES NOTED AND STARTED ON ANTI HYPERTENSIVES.PATIENT IS

BEING DISCHARED IN HEMODYNAMICALLY STABLE STATE

Investigation

HEMOGRAM 13-05-2025

 HAEMOGLOBIN 11.6 gm/dlTOTAL COUNT 12,100 cells/cummNEUTROPHILS 75

%LYMPHOCYTES 15 %EOSINOPHILS 01 %MONOCYTES 09 %BASOPHILS 00 %PCV 33.7 vol

%M C V 96.9 flM C H 33.4 pgM C H C 34.5 %RDW-CV 13.3 %RDW-SD 46.7 flRBC COUNT 3.48

millions/cummPLATELET COUNT 2.08 lakhs/cu.mmSMEARRBC NORMOCYTIC

NORMOCHROMICWBC With in normal limitsPLATELETS AdeqauteHEMOPARASITES No

hemoparasites seenIMPRESSIONNORMOCYTIC NORMOCHROMIC WITH LEUKOCYTOSIS

EOSINOPHILS 02 %MONO

HEMOGRAM 14-05-2025

HAEMOGLOBIN 11gm/dlTOTAL COUNT 11,000 cells/cummNEUTROPHILS 68 %LYMPHOCYTES

20 %

CYTES 10%BASOPHILS 00 %PCV 32.2 vol %M C V 98.5 flM C H 32.2 pgM C H C 33.4 %RDW-CV

13.4 %RDW-SD 47.0 flRBC COUNT 3.27 millions/cummPLATELET COUNT 1.90

lakhs/cu.mmSMEARRBC NORMOCYTIC NORMOCHROMICWBC With in normal limitsPLATELETS

AdeqauteHEMOPARASITES No hemoparasites seenIMPRESSIONNORMOCYTIC

NORMOCHROMIC BLOOD

HEMOGRAM 15-05-2025

HAEMOGLOBIN 9.2 gm/dlTOTAL COUNT 9,500 cells/cummNEUTROPHILS 64 %LYMPHOCYTES

23 %EOSINOPHILS 03 %MONOCYTES 10 %BASOPHILS 00 %PCV 27.1 vol %M C V 97.6 flM C H

33.2 pgM C H C 34.0 %RDW-CV 13.3 %RDW-SD 47.0 flRBC COUNT 2.78 millions/cummPLATELET

COUNT 1.79 lakhs/cu.mmSMEARRBC NORMOCYTIC NORMOCHROMICWBC With in normal

limitsPLATELETS AdeqauteHEMOPARASITES No hemoparasites

seenIMPRESSIONNORMOCYTIC NORMOCHROMIC BLOOD

Anti HCV Antibodies - RAPID 13-05-2025 08:55:PM Non ReactiveRFT 13-05-2025 08:55:PMUREA

16 mg/dl 50-17 mg/dlCREATININE 0.8 mg/dl 1.2-0.6 mg/dlURIC ACID 2.9 mmol/L 6-2.6

mmol/LCALCIUM 9.8 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.1 mg/dl 4.5-2.5 mg/dlSODIUM 131

mmol/L 145-136 mmol/LPOTASSIUM 4.3 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 105 mmol/L 98-107

mmol/L

LIVER FUNCTION TEST (LFT) 13-05-2025 08:55:PMTotal Bilurubin 1.96 mg/dl 1-0 mg/dlDirect

Bilurubin 0.30 mg/dl 0.2-0.0 mg/dlSGOT(AST) 27 IU/L 31-0 IU/LSGPT(ALT) 12 IU/L 34-0

IU/LALKALINE PHOSPHATASE 158 IU/L 128-56 IU/LTOTAL PROTEINS 5.8 gm/dl 8.3-6.4

gm/dlALBUMIN 3.4 gm/dl 4.5-2.9 gm/dlA/G RATIO 1.45URINCOMPLETE E EXAMINATION (CUE)

13-05-2025 08:55:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY

1.010ALBUMIN TraceSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL

CELLS 2-4RED BLOOD CELLS 4-6CRYSTALS NilCASTS NilAMORPHOUS DEPOSITS

AbsentOTHERS Nil

2D ECHO BED SIDE:DONE ON 14/05/25

NO RWMA,MILD LVH +

TRIVIAL TR/AR/MR ; NO PAH; NO PR

SCLEROTIC AV :NO AS/MS

EJECTION FRACTION =65%

GOOD LV SYSTOLIC FUNCTIONS

GRADE 1 DIASTOLIC DYSFUNCTION

IVC SIZE (1.39CMS) COLLAPSING

NO PE:NO LV CLOT

HEMOGRAM 19-05-2025

HAEMOGLOBIN 9.4gm/dlTOTAL COUNT 8900 cells/cummNEUTROPHILS 67 %LYMPHOCYTES

21 %

EOSINOPHILS 3%

MONOCYTES 9BASOPHILS 00 %PCV 32.2 vol %M C V 98.5 flM C H 32.2 pgM C H C 33.4 %RDWCV 13.4 %RDW-SD 47.0 flRBC COUNT 2.81 millions/cummPLATELET COUNT 2.48

lakhs/cu.mmSMEARRBC NORMOCYTIC NORMOCHROMICWBC With in normal limitsPLATELETS

AdeqauteHEMOPARASITES No hemoparasites seenIMPRESSIONNORMOCYTIC

NORMOCHROMIC BLOOD

CUE ON 19/5/25COLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY

1.010ALBUMIN TraceSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL

CELLS 2-3RED BLOOD CELLS NILCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS

AbsentOTHERS Nil

LIPID PROFILE:

TOTAL CHOLESTEROL:85MG/DL

TRIGLYCERIDES:76MG/DL

HDL CHOLESTEROL:29MG/DL

LDL CHOLESTEROL:53.5MG/DL

VLDL CHOLESTEROL:50.2MG/DL

LFT DONE ON :19/5/25

Total Bilurubin 1.10 mg/dl 1-0 mg/dlDirect Bilurubin 0.21 mg/dl 0.2-0.0 mg/dlSGOT(AST) 39 IU/L 31-0

IU/LSGPT(ALT) 19IU/L 34-0 IU/LALKALINE PHOSPHATASE 156 IU/L 128-56 IU/LTOTAL

PROTEINS 5.6 gm/dl 8.3-6.4 gm/dlALBUMIN 3.1 gm/dl 4.5-2.9 gm/dlA/G RATIO 1.29

RFT DONE ON 19/5/25UREA 13mg/dl 50-17 mg/dlCREATININE 0.7 mg/dl 1.2-0.6 mg/dlURIC ACID

3.1mmol/L 6-2.6 mmol/LCALCIUM 10mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.8 mg/dl 4.5-2.5

mg/dlSODIUM 133 mmol/L 145-136 mmol/LPOTASSIUM 3.7 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

102 mmol/L 98-107 mmol/L PROTHROMBIN TIME DONE ON 19/5/25

PT TIME:17.3 SECONDS

INR:1.2

HBA1C:6.0%

FBS:90 MG/DL

APTT:33SECONDS

T3- 0.61 NG/ML

T4- 11.7 MICRO G/DL

TSH - 3.97 MICRO LU/ML

Treatment Given(Enter only Generic Name)

INJ.CLEXANE 60 MG S/C OD 8AM FOR 4 DAYS

TAB.APIXABAN 2.5MG PO/BD 8AM-0-8PM FOR 4 DAYS

TAB.ECOSPRIN 75 MG PO/OD 8AM

TAB ATORVASTIN 40 MG PO/HS 8PM

TAB.BISOPROLOL 2.5 MG PO/BD 8AM--X--8PM

TAB.TELMISARTAN 40MG PO/OD 8AM FOR ONE DAY

TAB.TELMA-AM 40/5 PO/OD 8AM FOR ONE DAY

TAB.TELMASARTON 40MG + AMLODIPINE 5MG +HYDROCHLORTHIAZIDE 12.5MG FOR ONE

DAY

PHYSIOTHERAPY OF LT UL AND LL

FREQUENT POPSITION CHANGE 2ND HOURLY

Advice at Discharge

TAB. APIXABAN 2.5 MG PO/BD 8AM--X--8PM CONTINUE

TAB.ECOSPRIN 75 MG PO/OD 8AM CONTINUE

TAB ATORVASTIN 40 MG PO/HS 8PM CONTINUE

TAB.BISOPROLOL 2.5 MG PO/BD 8AM--X--8PM CONTINUE

TAB.TELMASARTON 40MG + AMLODIPINE 5MG +HYDROCHLORTHIAZIDE 12.5MG PO/OD 8AM

TO CONTINUE

TAB.AMLONG 5MG PO/OD 0-0-1 @8PM

PHYSIOTHERAPY OF LT UL AND LL

FREQUENT POPSITION CHANGE 2ND HOURLY

 PLAN TO START ORAL HYPOGLYCEMIC AGENTS IN THE NEXT VISIT

Follow Up

REVIEW TO GM OPD AFTER 1 WEEK

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 31

60years/MALE

D. O. A : 22/04/2025

D. O. D : 26/04/2025

Diagnosis

ALTERED SENOSORIUM (RESOLVED )SECONDARY TO UREAMIA ? SEPSIS

ACUTE CVA -MULTIPLE INFARCTS IN R CEEREBRAL AND CEREBELLAR HEMISPHERE

CEREBRAL MYELOID ANGIOPATHY

PAROXYSMAL ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE

HIGH SAAG LOW PROTEIN ASCITIS

ACUTE KIDNEY INJURY ON CKD

ANEMIA OF CHRONIC DISEASE

S/P 3 SESSIONS OF HAEMODIALYSIS

HTN

HFMEF (EF -59%)

HYPOTHYROIDISM

Case History and Clinical Findings

C/O SLURRING OF SPEECH SINCE 3DAYS

ABDOMINAL DISTENSION SINCE 3 DAYS

DECREASED URINE OUTPUT SINCE 2 DAYS

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 8 DAYS AGO THEN HE DEVELOPED

LOOSE STOOLS 3 TO 4 EPISODES PER DAY

PATIENT WENT TO OUTSIDE HOSPITAL AND TREATED THERE NOW RESOLVED. SINCE 3

DAYS PATIENT DEVELOPED SLURRING OF SPEECH INSIDIOUS IN ONSET,GRADUALLY

PROGRESSIVE WITH ABDOMINAL DISTENSION

H/O DECREASED URINE OUTPUT SINCE 2 DAYS[BED WETTING]

NO H/O SOB, CHEST PAIN,PALPITATIONS,ORTHOPNEA,

PND,HEADACHE,GIDDINESS,BLURRING OF VISION,DIPLOPIA

PAST HISTORY:

K/C/O HTN SINCE 3YRS ON TAB.CILINDIPINE 10 MG OD

HYPOTHYROIDISM ON TAB. THYRONORM 12.5 MG OD

NO H/O DM,ASTHMA,TB,EPILEPSY,CVA ,CAD

PERSONAL HISTORY: MARRIED

APETTITE NORMAL

BOWEL REGULAR

MICTURITION DECREASED SINCE 2 DAYS

FAMILY HISTORY: NOT SIGNIFICANT

GENERAL EXAMINATION: PALLOR PRESENT

NO ICTERUS,CYNOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA

BP:180/100MMHG

PR -140BPM

RR -16CPM

TEMP - 99.9F

SYSTEMIC EXAMINATION:

CVS - S1 S2 NO MURMURS

RS - BAE NVBS

P/A -SOFT NON TENDER

Investigation

BsAg-RAPID22-04-2025 03:59:PMNegative Anti HCV Antibodies - RAPID22-04-2025 03:59:PMNon

Reactive COMPLETE URINE EXAMINATION (CUE) 22-04-2025 03:59:PMCOLOURPale

yellowAPPEARANCECloudyREACTIONAcidicSP.GRAVITY1.010ALBUMIN++++SUGARNilBILE

SALTSNilBILE PIGMENTSNilPUS CELLSPlentyEPITHELIAL CELLS0-1RED BLOOD CELLS0-

1CRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilRFT 22-04-2025

03:59:PMUREA143 mg/dlCREATININE11.2 mg/dlURIC ACID6.6 mmol/LCALCIUM10.1

mg/dlPHOSPHOROUS5.1 mg/dlSODIUM139 mmol/LPOTASSIUM4.5 mmol/L.CHLORIDE107

mmol/LABG 22-04-2025 03:59:PMPH7.21PCO222.0PO292.4HCO38.6St.HCO310.9BEB-17.8BEecf-

17.8TCO219.0O2 Sat96.4O2 Count10.7LIVER FUNCTION TEST (LFT) 22-04-2025 03:59:PMTotal

Bilurubin0.75 mg/dlDirect Bilurubin0.19 mg/dlSGOT(AST)19 IU/LSGPT(ALT)13 IU/LALKALINE

PHOSPHATASE276 IU/LTOTAL PROTEINS5.3 gm/dlALBUMIN2.16 gm/dlA/G RATIO0.69ABG 22-

04-2025 10:33:PMPH7.252PCO242.0PO267.9HCO317.9St.HCO317.6BEB-8.3BEecf-

8.0TCO238.5O2 Sat89.8O2 Count12.6ABG 23-04-2025

01:55:AMPH7.39PCO230.9PO236.0HCO318.7St.HCO319.6BEB-5.6BEecf-5.3TCO243.2O2

Sat63.3O2 Count0.46RFT 23-04-2025 01:55:AMUREA84 mg/dlCREATININE7.5 mg/dlURIC ACID4.2

mmol/LCALCIUM9.2 mg/dlPHOSPHOROUS3.5 mg/dlSODIUM146 mmol/LPOTASSIUM3.9

mmol/L.CHLORIDE106 mmol/LT3, T4, TSH 23-04-2025 01:55:AMT30.29 ng/mlT43.65 micro

g/dlTSH12.33 micro Iu/mlRFT 24-04-2025 12:32:AMUREA46 mg/dlCREATININE4.9 mg/dlURIC

ACID2.8 mmol/LCALCIUM8.9 mg/dlPHOSPHOROUS2.7 mg/dlSODIUM143 mmol/LPOTASSIUM3.2

mmol/L.CHLORIDE105 mmol/LRFT 24-04-2025 11:59:PMUREA55 mg/dlCREATININE5.8

mg/dlURIC ACID3.8 mmol/LCALCIUM9.2 mg/dlPHOSPHOROUS3.5 mg/dlSODIUM143

mmol/LPOTASSIUM3.5 mmol/L.CHLORIDE106 mmol/

Treatment Given(Enter only Generic Name)

1.RT FEEDS 100ML MILK WITH PROTEIN POWDER 4TH HOURLY AND 50ML WATER 2ND

HOURLY

2.I V FLUID NS AT 50ML/HR

3.INJ PIPTAZ 2.25GM IV/TID

4.INJ.METROGYL 500MG IV/TID

5. INJ PAN 40MG IV/OD

6.INJ HEPARIN 5000IV/TID

7.INJ EPO 4000IU S/C WEEKL;Y ONCE

8.INJ IRON SUCROSE 1 AMP IN 100ML NS IV/OD ON ALTERNATE DAYS

9.TAB MET-XL 50MG RT/OD

10. TAB CINOD 10MG RT/OD

11.TAB THYRONORM 25MCG RT/OD

12.TAB SHELCAL CT RT/OD

13. GRBS 4TH HOURLY

14. STRICT I/O CHARTING

15. VITALS CHARTING 2ND HOURLY

NEBULIOSATION WITH BUDECORT 12TH HOURLY AND IPRAVENT 6TH HOURLY

Advice at Discharge

TAB.TAXIM 200MG BD X2DAYS

TAB.METROGYL 400MG TID X 2DAYS

TAB.PAN 40MG OD

TAB.CINOD 10MG OD

TAB.MET XL 50MG OD

TAB.THYRONORM 25MCG OD BEFORE BREAKFAST

TAB.ECOSPRIN AV (75/20) PO HS

Follow Up

REVIEW AFTER 4DAYS TO THE NEPHROLOGY OPD OR SOS.

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 32

78years/MALE

D. O. A : 09/04/2025

D. O. D : 21/04/2025

Diagnosis

PERSISTENT AF WITH FVR

CARDIOGENIC SHOCK SECONDARY TO CAD WITH HFpEF(EF 51%)

ORAL PEMPHIGUS

ANEMIA OF CHRONIC DISEASE

RT INGUINAL HERNIA WITH PHIMOSIS

Case History and Clinical Findings

CHIEF COMPLAINTS :

C/O DRIBBLING OF URINE SINCE 2 DAYS

C/O SWELLING IN THE RIGHT SIDE SINCE 3 YEARS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 DAYS AGO THEN DEVELOPED DIFFICULTY

IN PASSING URINE WITH DRIBBLING OF URINE WHICH IS INSIDIOUS IN ONSET AND

GRADUALLY PROGRESSIVE

NO H/O BURNING MICTURITION

H/O FEVER ASSOCIATED WITH LOOSE STOOLS AND VOMITINGS 2-3 EPISODES PER DAY 5

DAYS AGO

NO H/O TRAUMA

H/O COUGH WITH EXPECTORATION (WHITE) 3 DAYS

NO H/O HEMATURIA OR PYURIA

PATIENT WAS TRANSFERRED FROM GEN SURGERY TO GEN MEDICINE I/V/O ATRIAL

FIBRILLATION AND PRE RENAL AKI SECONDARY TO SEPSIS ON 10/04/25

PAST HISTORY:

NO SIMILAR COMPLAINTS IN THE PAST

N/K/C/O DM,HTN,CVA,CAD,HYPOTHYROIDISM,TB,ASTHMA

PERSONAL HISTORY:

APPETITE - NORMAL

BOWELS- NORMAL

BLADDER-NORMAL

SLEEP- ADEQUATE

NO ALLERGIES

ADDICTIONS -ALCOHOL- STOPPED 6 MONTHS AGO

 TOBACCO - H/O SMOKING FOR APPROXIMATELY 50 YEARS STOPPED SINCE 1 YEAR

GENERAL EXAMINATION:

PATIENT IS C/C/C

TEMPERATURE - AFEBRILE

BP - 110/80 MMHG

PR - 90 BPM

RR - 21 CPM

SPO2 - 96 % AT RA

NO PALLOR, ICTERUS, CYANOSIS, LYMPHADENOPATHY, CLUBBING, GENERALISED EDEMA

SYSTEMIC EXAMINATION

CVS - S1 S2 HEARD, NO MURMURS

RS - BAE PRESENT, NVBS HEARD

P/A -SOFT,TENDER AT HYPOGATRIC,RIGHT ILAIC REGION , NO ORGANOMEGALY , BOWEL

SOUNDS PRESENT

CNS- NFND

LOCAL EXAMINATION OF INGUINOSCROTAL REGION

EXAMINATION O F RIGHT SIDE

ON INSPECTION -

A SOLITARY OVAL SWELLING OF SIZE OF 5X6 CM + IN THE RIGHT GROIN EXTENDING FROM

DEEP RING TO THE 2 CMS ABOVE THE ROOT OF THE SCROTUM

SMOOTH SURFACE

REDUCIBLE ON LYING DOWN WITH VISIBLE COUGH IMPULSE

NO VISIBLE PULSATIONS / ENGORGED VEINS

NO VISIBLE LYMPHADENOPATHY

GLANS IS COVERED BY PREPAUCE WITH TINY MEATUS VISIBLE

ON PALPATION -

NO LOCAL RISE OF TEMPERATURE

NO TENDERNESS

GET ABOVE THE SWELLING -VE

SURFACE IS SMOOTH WITH SOFT IN CONSISTENCY

COUGH IMPULSE PRESENT WITH DEEP RING OCCLUSION TEST POSITIVE

NO PALPABLE LYMOADENOPATHY

UNABLE TO RETRACT PREPUCE OVER THE GLANS

ON PERCUSSION - DULL NOTE HEARD

AUSCULTATION - BS +

DERMA REFFERAL DONE ON 11.4.25

DIAGNOSIS:APHTHOUS ULCER

ADVICED

TAB BICOSULES LA OD X 2 WEEKS

SORE GEL L/A TID BEFORE FOOD X 2 WEEKS

DIAGNOSIS- ORAL PEMPHIGUS

TOSTI GEL L/A BD X 2 WEEKS

BETADINE MOUTH GARGLE TID X 2 WEEKS

NORMAL SALINE COMPRESS TID

TAB.PREDNISOLONE 5MG PO TID X 10 DAYS

TAB PAN 40MG PO OD X 10 DAYS

COURSE IN THE HOSPTAL

78 YEARS OLD MALE CAME WITH ABOVE MENTIONED COMPLAINTS WAS TRANSFERED

FROM GEN SURGERY TO GEN MEDICINE I/V/O ATRIAL FIBRILLATION,PRERENAL AKI

SECONDARY TO SEPSIS ON FURTHER EVALUATION AND EXAMINATION WAS DIAGNOSED

AS PERSISTENT ATRIAL FIBRILLATION WITH FVR ,CARDIOGENIC SHOCK SECONDARY TO

CAD,HFPef,ANEAMIA OF CHRONIC DISEASE , ORAL PEMPHIGUS,RIGHT INGUINAL HERNIA

WITH PHIMOSIS.PATIENT WAS STARTED ON RATE CONTROLLING

AGENTS,ANTIARRYTHMICS,ANTICOAGULANTA I/V/O ATRIAL FIBRILLATION AND WAS PUT

ON TRIPLE IONOTROPES SUPPORTS I/V/O HYPOTENSION.INJ PIPTAZ INJ DOXYCYCLINS

TAB FLUCONOZOLE WAS STARTED I/V/O SEPSIS .PATIENT WAS TREATED

CONSERVATIVELY PRE RENAL AKI RESOLVED.PATIENT IS HEMODYNAMICALLY STABLE

HENCE BEING DISCHARGED.

Investigation

RFT 09-04-2025 09:24:PMUREA 195 mg/dl 50-17 mg/dlCREATININE 2.7 mg/dl 1.3-0.8 mg/dlURIC

ACID 6.7 mmol/L 7.2-3.5 mmol/LCALCIUM 9.6 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.6 mg/dl 4.5-

2.5 mg/dlSODIUM 136 mmol/L 145-136 mmol/LPOTASSIUM 4.6 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

103 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 09-04-2025 09:24:PMTotal Bilurubin 1.84 mg/dl 1-0 mg/dlDirect

Bilurubin 0.90 mg/dl 0.2-0.0 mg/dlSGOT(AST) 67 IU/L 35-0 IU/LSGPT(ALT) 50 IU/L 45-0

IU/LALKALINE PHOSPHATASE 437 IU/L 128-56 IU/LTOTAL PROTEINS 5.0 gm/dl 8.3-6.4

gm/dlALBUMIN 2.5 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.02HBsAg-RAPID 09-04-2025 09:24:PM

Negative

Anti HCV Antibodies - RAPID 09-04-2025 09:24:PM Non ReactiveCOMPLETE BLOOD PICTURE

(CBP) 09-04-2025 09:24:PMHAEMOGLOBIN 9.7 gm/dl 17.0-13.0 gm/dlTOTAL COUNT 17800

cells/cumm 10000-4000 cells/cummNEUTROPHILS 77 % 80-40 %LYMPHOCYTES 12 % 40-20

%EOSINOPHILS 01 % 6-1 %MONOCYTES 10 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET

COUNT 90,000SMEAR Normocytic normochromic anemia with leukocytosis and thrombocytophenia

COMPLETE URINE EXAMINATION (CUE) 09-04-2025 09:24:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-4RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilSERUM

ELECTROLYTES (Na, K, C l) 10-04-2025 06:32:PMSODIUM 134 mmol/L 145-136

mmol/LPOTASSIUM 4.6 mmol/L 5.1-3.5 mmol/LCHLORIDE 99 mmol/L 98-107 mmol/L

RFT 10-04-2025 06:54:PMUREA 150 mg/dl 50-17 mg/dlCREATININE 1.8 mg/dl 1.3-0.8 mg/dlURIC

ACID 5.8 mmol/L 7.2-3.5 mmol/LCALCIUM 10.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.61 mg/dl

4.5-2.5 mg/dlSODIUM 134 mmol/L 145-136 mmol/LPOTASSIUM 4.6 mmol/L. 5.1-3.5

mmol/L.CHLORIDE 99 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 10-04-2025

06:54:PMTotal Bilurubin 1.58 mg/dl 1-0 mg/dlDirect Bilurubin 0.92 mg/dl 0.2-0.0 mg/dlSGOT(AST) 48

IU/L 35-0 IU/LSGPT(ALT) 40 IU/L 45-0 IU/LALKALINE PHOSPHATASE 524 IU/L 128-56 IU/LTOTAL

PROTEINS 5.3 gm/dl 8.3-6.4 gm/dlALBUMIN 2.47 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.87

COMPLETE URINE EXAMINATION (CUE) 10-04-2025 06:54: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 NilABG 10-04-2025

09:44:PMPH 7.37PCO2 26.5PO2 87.6HCO3 15.0St.HCO3 17.2BEB -8.9BEecf -9.3TCO2 31.8O2 Sat

96.5O2 Count 11.9

RFT 11-04-2025 03:03:AMUREA 141 mg/dl 50-17 mg/dlCREATININE 1.6 mg/dl 1.3-0.8 mg/dlURIC

ACID 5.3 mmol/L 7.2-3.5 mmol/LCALCIUM 10.2 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.55 mg/dl

4.5-2.5 mg/dlSODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 4.4 mmol/L. 5.1-3.5

mmol/L.CHLORIDE 100 mmol/L 98-107 mmol/LSTOOL FOR OCCULT BLOOD 11-04-2025

06:04:PM Negative (-ve)

BLOOD UREA 11-04-2025 11:10:PM 100 mg/dl 50-17 mg/dlSERUM CREATININE 11-04-2025

11:10:PM 1.2 mg/dl 1.3-0.8 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 11-04-2025 11:10:PMSODIUM 135 mmol/L 145-136

mmol/LPOTASSIUM 4.3 mmol/L 5.1-3.5 mmol/LCHLORIDE 98 mmol/L 98-107 mmol/LRFT 12-04-

2025 11:18:PMUREA 76 mg/dl 50-17 mg/dlCREATININE 1.2 mg/dl 1.3-0.8 mg/dlURIC ACID 4.4

mmol/L 7.2-3.5 mmol/LCALCIUM 10.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.9 mg/dl 4.5-2.5

mg/dlSODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 3.9 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 98

mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 12-04-2025 11:18:PMTotal Bilurubin 1.24 mg/dl 1-0 mg/dlDirect

Bilurubin 0.51 mg/dl 0.2-0.0 mg/dlSGOT(AST) 19 IU/L 35-0 IU/LSGPT(ALT) 24 IU/L 45-0

IU/LALKALINE PHOSPHATASE 360 IU/L 128-56 IU/LTOTAL PROTEINS 5.2 gm/dl 8.3-6.4

gm/dlALBUMIN 2.5 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.90COMPLETE URINE EXAMINATION (CUE)

13-04-2025 09:30:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY

1.010ALBUMIN +SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-4EPITHELIAL

CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS

AbsentOTHERS Nil

COMPLETE URINE EXAMINATION (CUE) 13-04-2025 11:23:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 3-6EPITHELIAL CELLS 2-4RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilRFT 14-04-2025

05:32:AMUREA 65 mg/dl 50-17 mg/dlCREATININE 1.1 mg/dl 1.3-0.8 mg/dlURIC ACID 3.3 mmol/L

7.2-3.5 mmol/LCALCIUM 9.4 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.9 mg/dl 4.5-2.5 mg/dlSODIUM

133 mmol/L 145-136 mmol/LPOTASSIUM 4.0 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 99 mmol/L 98-107

mmol/L

RFT 15-04-2025 12:02:AMUREA 67 mg/dl 50-17 mg/dlCREATININE 1.2 mg/dl 1.3-0.8 mg/dlURIC

ACID 2.7 mmol/L 7.2-3.5 mmol/LCALCIUM 9.5 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.8 mg/dl 4.5-

2.5 mg/dlSODIUM 132 mmol/L 145-136 mmol/LPOTASSIUM 4.5 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

96 mmol/L 98-107 mmol/LRFT 15-04-2025 10:26:PMUREA 56 mg/dl 50-17 mg/dlCREATININE 1.2

mg/dl 1.3-0.8 mg/dlURIC ACID 2.7 mmol/L 7.2-3.5 mmol/LCALCIUM 10.0 mg/dl 10.2-8.6

mg/dlPHOSPHOROUS 2.6 mg/dl 4.5-2.5 mg/dlSODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM

3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 96 mmol/L 98-107 mmol/L

ABG 16-04-2025 09:09:PMPH 7.45PCO2 30.1PO2 82.8HCO3 20.9St.HCO3 22.6BEB -2.1BEecf -

2.4TCO2 44.3O2 Sat 96.9O2 Count 10.6RFT 16-04-2025 11:47:PMUREA 52 mg/dl 50-17

mg/dlCREATININE 1.1 mg/dl 1.3-0.8 mg/dlURIC ACID 3.0 mmol/L 7.2-3.5 mmol/LCALCIUM 10.0

mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.1 mg/dl 4.5-2.5 mg/dlSODIUM 129 mmol/L 145-136

mmol/LPOTASSIUM 3.3 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 99 mmol/L 98-107 mmol/L

HEMOGRAM (13/04/25)HAEMOGLOBIN 10.1 gm/dlTOTAL COUNT 12,800 cells/cumm

NEUTROPHILS 70 % LYMPHOCYTES 10 % EOSINOPHILS 02 % MONOCYTES 08% BASOPHILS

00 % PCV 28.4 vol % M C V 86.1 fl M C H 32.2 pgM C H C 37.4 %RDW-CV 15.2 %RDW-SD 50.1 fl

RBC COUNT 3.3 millions/cummPLATELET COUNT 1.00 lakhs/cu.mm

HEMOGRAM (14/04/25)HAEMOGLOBIN 9.1 gm/dlTOTAL COUNT 11,500 cells/cumm

NEUTROPHILS 75 % LYMPHOCYTES 10 % EOSINOPHILS 02 % MONOCYTES 12% BASOPHILS

01 % PCV 24.4 vol % M C V 87.1 fl M C H 32.2 pgM C H C 37.4 %RDW-CV 15.2 %RDW-SD 50.1 fl

RBC COUNT 2.85 millions/cummPLATELET COUNT 1.50 lakhs/cu.mm

 HEMOGRAM (15/04/25)HAEMOGLOBIN 8.3 gm/dlTOTAL COUNT 9,800 cells/cumm

NEUTROPHILS 79 % LYMPHOCYTES 08 % EOSINOPHILS 00 % MONOCYTES 13% BASOPHILS

00% PCV 24.4 vol % M C V 87.1 fl M C H 32.2 pgM C H C 37.4 %RDW-CV 15.2 %RDW-SD 50.1 fl

RBC COUNT 2.55 millions/cummPLATELET COUNT 1.30 lakhs/cu.mm

HEMOGRAM (16/04/25)HAEMOGLOBIN 9.0 gm/dlTOTAL COUNT 10,500 cells/cumm

NEUTROPHILS 80 % LYMPHOCYTES 10 % EOSINOPHILS 01 % MONOCYTES 9% BASOPHILS

00 % PCV 25.4 vol % M C V 91.1 fl M C H 32.2 pgM C H C 35.4 %RDW-CV 16.2 %RDW-SD 50.1 fl

RBC COUNT 2.78 millions/cummPLATELET COUNT 1.40 lakhs/cu.mm

HEMOGRAM (17/04/25)HAEMOGLOBIN 9.1 gm/dlTOTAL COUNT 9,500 cells/cumm

NEUTROPHILS 75 % LYMPHOCYTES 10 % EOSINOPHILS 02 % MONOCYTES 10% BASOPHILS

00 % PCV 24.4 vol % M C V 91.1 fl M C H 32.2 pgM C H C 35.4 %RDW-CV 15.2 %RDW-SD 50.1 fl

RBC COUNT 2.85 millions/cummPLATELET COUNT 1.880 lakhs/cu.mm

2D ECHO REPORT SCREENING 12/04/25

AF DURING STUDY

MILD MR

MODERATE TR WITH PAH

MILD AR

SCLEROTIC AV NO AS/MS IAS INTACT

PARADOXICAL IVS EF 52%

FAIR LV SYSTOLIC FUNCTIONS

GRADE II DIASTOLIC DYSFUNCTION

NO PE NO LV CLOT

DILATED RA SIZERV SIZE

MILD DILATED

IVC SIZE COLLAPSING

REVIEW 2D ECHO 14/4/25

AF DURING STUDY

RWMA + MILD ANTEROSEPTAL HYPOKINESIA

MODERATE TR WITH PAH

MILD AR+ MILD MR+ SEVERE TR+ WITH MODERATE PAH TRIVIAL PR+

SCLEROTIC AV NO AS/MS IAS INTACT/ANEURISM

EF 51% ,RVSP2 48+10 58 MMHG

FAIR LV SYSTOLIC FUNCTIONS

GRADE II DIASTOLIC DYSFUNCTION+

NO PE NO LV CLOT

DILATED RA SIZE (6.24 CMS)RV SIZE(4.5 CMS)

DILATED LA

IVC SIZE INTACT(1.18 CMS)

USG ON 9.4.25

FINDINGS:

E/O 21MM DEFECT NOTED IN THE RT INGUINAL REGION WITH OMENTUM AND BOWEL AS

HERNIATING CONTENT

B/L TESTIS AND NORMAL S/E AND NORMAL VASCULARITY

B/L SPERMATIC CORD NORMAL

B/L EPIDYDIMIS NORMAL

NO E/O INGUINAL LYMPHADENOPATHY

E/O MILD FLUID WITH INTERNAL ECHOES NOTED IN THE RIOGHT SCROTAL SAC

RT INGUINAL HERNIA WITH OMENTUM AND BOWEL AS HERNIATING CONTENT

RT MILD HYDROCELE

USG ON 9.4.25

E/OP SMALL HYPERECHOIC FOCUS MEASURING 4 MM NOTED IN THE DILATED CBD

?CALCULUS

E/O 23X22 MM CYST NOTED IN THE UPPER POLE OF RIGHT KIDNEY

RIGHT RENAL CORTICAL CYST

USG DONE ON 13.4.25

VISUALISED BOWEL LOOPS APPEARS COLLAPSED

NO E/O ANY INTERBOWEL FLUID

CBD APPEARS DIALATED

BLOOD FOR C/S 12/4/25

1ST SC

NO GROWTH AFTER 48 HOURS OF AEROBIC INCUBATION

BLOOD FOR C/S 12/4/25 2ND SAMPLE

1ST SC

NO GROWTH AFTER 48 HOURS OF AEROBIC INCUBATION

URINE FOR C/S 12/4/25

1-2 PUS CELLS SEEN

NO BACTERIAL GROWTH

BLOOD FOR C/S(RIGHT) REPORTED ON 16/4/25

NO GROWTH AFTER 1 WEEK OF AEROBIC INCUBATION

BLOOD FOR C/S(LEFT) REPORTED ON 16/4/25

NO GROWTH AFTER 1 WEEK OF AEROBIC INCUBATION

URINE FOR C/S ON 15/4/25

NO BACTERIAL GROWTH

Treatment Given(Enter only Generic Name)

RT FEED 200ML MILK WITH PROTEIN POWDER 4TH HRLY

100ML MILK 2 ND HRLY

IVF DNS @ 50 ML /HR

INJ.NORADRENALINE 4 ML IN 46 ML NS @ 1ML/HR

INJ.VASOPRESSIN 2ML IN 38ML NS @ 4.4ML/HR

INJ DOBUTAMINE 1AMP IN 45 ML NS @6ML/HR

INJ PIPTAZ 2.25GM IV QID

INJ LASIX INFUSION 100MG @ 3ML/HR

TAB METXL 50MG RT OD

TAB METXL 25MG RT OD

TAB CARDRONE 200MG RT OD

TAB PCM 650MG RT QID

TAB LIMCEE RT OD

TAB PREDNISOLONE 5MG RT OD

TAB PAN 40MG RT OD

TAB RIBOLAVIN 10MG RT OD

TAB DABIGATRAN 110MG RT BD

TAB ECOSPRIN AV 75/20MG RT OD

TAB FLUCONOZOLE 150MG RT BD

 TOSTI GEL L/A

BETADINE MOUTH GARGLE

DVT STOCKING

Advice at Discharge

TAB DOXYCYCLIN 100 MG PO/BD X 3 DAYS

TAB LASIX 20 MG PO/BD X 2 WEEKS

TAB FLUCONAZOLE 150MG PO/BD X5 DAYS

TAB MET XL 25 MG PO/BD X 2 WEEEKS

TAB CARDRONE 200MG PO/OD X 2 WEEKS

TAB PREDNISOLONE 5 MG PO/BD X 5 DAYS

TAB ECOSPRIN AV 75/10 MG PO/OD TO BE CONTINUED

TAB LIMCEE PO/OD X 5 DAYS

TAB PAN 40 MG PO/OD BEFORE BREAKFAST X 5 DAYS

TAB PCM 650 MG PO/BD X 3DAYS

TOSTI GEL FOR L/A MOUTH ULCER THRICE DAILY X 1WEEK

BETADINE MOUTH WASH THRICE DAILY X 1 WEEK

Follow Up

REVIEW AFTER TWO WEEKS TO GM OPD OR SOS

REVIEW AFTER TWO WEEKS TO GS OPD FOR HERNIOPLASTY AND CERCUMCISION OR SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 33

63years/MALE

D. O. A : 01/04/2025

D. O. D : 11/04/2025

Diagnosis

SEPTIC SHOCK ? CARDIOGENIC SHOCK

PERSISTENT AF WITH FVR

HFMEF

NCNC ANEMIA SECONDARY ? BLOOD LOSS

B/L PLEURAL EFFUSION [R>L]

GRADE IV BEDSORE [B/L GLUTEAL REGION]

S/P D11-D12 LAMINECTOMY WITH PARAPARESIS

Case History and Clinical Findings

PATIENT CAME WITH C/O DIFFICULTY IN SWALLOWING AND SOB SINCE TODAY MORNING

[1/4/25]

HOPI: PATIENT WAS APPARENTLY NOT COMPLAINING OF DIFFICULTY IN SWALLOWING

,THEN HE SUDDENLY DEVELOPED DIFFICULTY IN SWALLOWING A/W DROOLING OF SALIVA

,SECRETIONS FROM MOUTH AND UNABLE TO SPEAK [APHASIA].SOB SUDDEN IN ONSET

GRADUALLY PROGRESSIVE GRADE 2 TO 3 NOT A/W ANY PALPITATIONS , PEDAL EDEMA

NO H/O FEVER COLD COUGH VOMITINGS NAUSEA

PAST HISTORY: NO SIMILAR COMPLAINTS IN THE PAST.

H/O FALL AT HOME WITH WEAKNESS OF BOTH LL WHICH HE DIAGONSED AS D11 WEDGE

FRACTURE WITH ANKYLOSING SPONDYLOSIS AND PARAPLEGIA. FRACTURE OF RIBS WITH

B/L BED SORE RIGHT HEMOTHORAX >LEFT HEMOTHORAX WITH ATRIAL FIBRILLATION

S/P D11 D12 LAMINECTOMY ,D9-D10,D12-L1 PEDICEL SCREW FIXATION [TITANIUM ROD AND

SCREWS] RIGHT SIDED ICD

N/K/C/O DM II , HTN,TB ,EPILEPSY,ASTHMA .CVA.CAD, THYROID DISORDERS,ASTHMA

PERSONAL HISTORY:DIET-MIXED APPETITE- NORMALBOWEL MOVEMENTSREGULARBLADDER- REGULARSLEEP- ADEQUATE

GENERAL EXAMINATION:PATIENT IS C/C/CNO

,PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMATEMP:

AFEBRILEBP:100/60 MMHGPR:100BPMRR:32CPMGRBS :196MG/DLSYSTEMIC

EXAMINATION:CVS:S1 S2 HEARD ,NO MURMURSRS:,BAE +,RT IAA FINE CREPTS

PRESENTPA:SOFT,NON TENDERCNS:

TONE RIGHT LEFT

UL N N

LL INCREASED INCREASED

POWER

UL 5/5 5/5

LL 1/5 1/5

COURSE IN THE HOSPITAL:

Investigation

RFT 01-04-2025 06:10:PMUREA 48 mg/dl 50-17 mg/dlCREATININE 1.0 mg/dl 1.3-0.8 mg/dlURIC

ACID 2.8 mmol/L 7.2-3.5 mmol/LCALCIUM 9.3 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.1 mg/dl 4.5-

2.5 mg/dlSODIUM 136 mmol/L 145-136 mmol/LPOTASSIUM 4.9 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

101 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 01-04-2025 06:10:PMTotal Bilurubin 1.04

mg/dl 1-0 mg/dlDirect Bilurubin 0.20 mg/dl 0.2-0.0 mg/dlSGOT(AST) 43 IU/L 35-0 IU/LSGPT(ALT) 40

IU/L 45-0 IU/LALKALINE PHOSPHATASE 294 IU/L 128-56 IU/LTOTAL PROTEINS 6.0 gm/dl 8.3-6.4

gm/dlALBUMIN 2.30 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.62COMPLETE URINE EXAMINATION (CUE)

01-04-2025 06:10: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 NilHBsAg-RAPID 01-04-2025 06:10:PM NegativeAnti HCV Antibodies - RAPID 01-

04-2025 06:10:PM Non ReactiveABG 01-04-2025 10:16:PMPH 7.37PCO2 25.7PO2 124HCO3

14.6St.HCO3 16.8BEB -9.4BEecf -9.6TCO2 31.9O2 Sat 98.5O2 Count 9.5RFT 03-04-2025

08:53:AMUREA 50 mg/dl 50-17 mg/dlCREATININE 0.9 mg/dl 1.3-0.8 mg/dlURIC ACID 2.5 mmol/L

7.2-3.5 mmol/LCALCIUM 9.4 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.8 mg/dl 4.5-2.5 mg/dlSODIUM

133 mmol/L 145-136 mmol/LPOTASSIUM 4.7 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 101 mmol/L 98-

107 mmol/LRFT 04-04-2025 06:34:AMUREA 29 mg/dl 50-17 mg/dlCREATININE 0.8 mg/dl 1.3-0.8

mg/dlURIC ACID 2.2 mmol/L 7.2-3.5 mmol/LCALCIUM 8.9 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.3

mg/dl 4.5-2.5 mg/dlSODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 4.2 mmol/L. 5.1-3.5

mmol/L.CHLORIDE 106 mmol/L 98-107 mmol/LRFT 04-04-2025 10:51:PMUREA 31 mg/dl 50-17

mg/dlCREATININE 0.8 mg/dl 1.3-0.8 mg/dlURIC ACID 2.2 mmol/L 7.2-3.5 mmol/LCALCIUM 8.9

mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.4 mg/dl 4.5-2.5 mg/dlSODIUM 135 mmol/L 145-136

mmol/LPOTASSIUM 4.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 99 mmol/L 98-107 mmol/LCOMPLETE

BLOOD PICTURE (CBP) 06-04-2025 07:11:AMHAEMOGLOBIN 8.0 g

m/dl 17.0-13.0 gm/dlTOTAL COUNT 7100 cells/cumm 10000-4000 cells/cummNEUTROPHILS 80 %

80-40 %LYMPHOCYTES 15 % 40-20 %EOSINOPHILS 02 % 6-1 %MONOCYTES 03 % 10-2

%BASOPHILS 00 % 2-0 %PLATELET COUNT 1.5SMEAR Normocytic normochromic anemiaRFT

06-04-2025 07:11: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 8.8 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.6 mg/dl 4.5-2.5

mg/dlSODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 4.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

100 mmol/L 98-107 mmol/LABG 06-04-2025 07:11:AMPH 7.38PCO2 27.1PO2 63.3HCO3

16.0St.HCO3 18.0BEB -7.8BEecf -8.1TCO2 34.4O2 Sat 91.9O2 Count 9.8RFT 06-04-2025

10:01:PMUREA 18 mg/dl 50-17 mg/dlCREATININE 0.8 mg/dl 1.3-0.8 mg/dlURIC ACID 1.9 mmol/L

7.2-3.5 mmol/LCALCIUM 9.3 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.78 mg/dl 4.5-2.5

mg/dlSODIUM 136 mmol/L 145-136 mmol/LPOTASSIUM 4.4 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

102 mmol/L 98-107 mmol/LRFT 07-04-2025 11:18:PMUREA 21 mg/dl 50-17 mg/dlCREATININE 0.7

mg/dl 1.3-0.8 mg/dlURIC ACID 1.6 mmol/L 7.2-3.5 mmol/LCALCIUM 8.9 mg/dl 10.2-8.6

mg/dlPHOSPHOROUS 2.7 mg/dl 4.5-2.5 mg/dlSODIUM 136 mmol/L 145-136 mmol/LPOTASSIUM

4.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 103 mmol/L 98-107 mmol/LRFT 08-04-2025 11:43:PMUREA

19 mg/dl 50-17 mg/dlCREATININE 0.7 mg/dl 1.3-0.8 mg/dlURIC ACID 1.7 mmol/L 7.2-3.5

mmol/LCALCIUM 8.5 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.49 mg/dl 4.5-2.5 mg/dlSODIUM 134

mmol/L 145-136 mmol/LPOTASSIUM 4.4 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 99 mmol/L 98-107

mmol/LSERUM ELECTROLYTES (Na, K, C l) 08-04-2025 11:43:PMSODIUM 134 mmol/L 145-136

mmol/LPOTASSIUM 4.4 mmol/L 5.1-3.5 mmol/LCHLORIDE 99 mmol/L 98-107 mmol/L

2D ECHO DONE ON 2/4/25

AF DURING STUDY

RWMA + LAD TERRITORY HYPOKINESIA

MILD MR+ TRIVIAL AR+ MILD TR+ NO PAH

SCLEROTIC AV NO AS/MS

IAS INTACT / ANEURSYSM

EF 44% RVSP 38-43MMHG

MILD TO MODERATE LV DYSFUNCTION

GRADE 1 DIASTOLIC DYSFUNCTION

NO PE,NO LV CLOT

IVC SIZE 1012CMS COLLAPSING

DILATED LA/LV

MILD DILATED RA/RV

Treatment Given(Enter only Generic Name)

HEAD END ELEVATION

RT FEEDS

INJ MEROPENEM 1 GM IV/TID X 6 DAYS

INJ VANCOMYCIN 1GM IV/BD X6 DAYS

INJ CLINDAMYCIN 600MG IV/BDX6 DAYS

INJ FLUCANAZOLE 200MG IV/BDX6 DAYS

TAB DILTIAZEM 30MG RT/TID

TAB PAN 40MG RT/OD

TAB ATROVAS 40MG RT/HS

TAB MVT RT/OD

NEB WITH MUCOMIST,IPRAVENT,BUDECORT SOS

MUPIROCIN OINT L/A TID

Advice at Discharge

HEAD END ELEVATION

RT FEEDS 100ML MILK WITH ALBURICH PROTEIN POWDER 4TH HRLY, 50ML WATER 2ND

HRLY

TAB FAROPENEM 200MG RT/BD 8AM -8PM X 1 WEEK

TAB DITIAZEM 30MG RT/TID 8AM-2PM-8PM TO CONTINUE

TAB MET XL 25MG RT/BD 8AM-8PM TO CONTINUE

TAB PAN 40MG RT/OD BEFORE BBF

TAB DOLO 650MG RT/SOS

BED SORE DRESSINGS EVERY ALTERNATE DAY

RYLES CARE AND FOLEYS CARE EXPLAINED TO PATIENT ATTENDER

MUPIROCIN OINTMENT FOR LOCAL APPLICATION

Follow Up

REVIEW TO GM OPD AFTER 2 WEEKS/SOS.

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 34

70years/FEMALE

D. O. A : 17/07/2025

D. O. D : 21/07/2025

Diagnosis

PAROXYSMAL ATRIAL FIBRILLATION WITHFAST VENTRICULAR RATE

HFPEF [ EF 62 % ]

K/C/O HYPERTENSION SINCE 4 MONTHS

Case History and Clinical Findings

C/O PEDAL EDEMA SINCE 10 DAYS

C/O SHORTNESS OF BREATHE SINCE 10 DAYS

HOPI :

PATIENT WAS APPARENTLY ASYMPYOMATIC 10 DAYS AGO THEN SHE HAS C/O PEDAL

EDEMA SINCE 10 DAYS WHICH WAS INSIDIOUS IN ONSET ,GRADUALLY PROGRESSIVE

FROME ANKLE TO BELOW ELBOW,PITTING TYPE,AGGREVATED ON PROLONGED STANDING

AND SITTING

C/O SHORTNESS OF BREATHE SINCE 10 DAYS ,INSIDIOUS IN ONSET ,PROGRESSED FROME

GRADE 1 (NYHA) TO GRADE 2(NYHA)(80B ON WALKING)

NO C/O COUGH,PALPITATIONS,CHEST PAIN,ABDOMINAL PAIN

NO C/O VOMITING,LOOSE STOOLS,BURNING MICTURITION,DECREASED URINE

OUTPUT,FACIAL PUFFINESS

C/O CONSTIPATION SINCE 1 YR,PASSES HARD STOOLS ONCE IN 3-4 DAYS ,NON BLOOD

STAINED, NO PAIN WHILE DEFECATION

C/O TINGLING SENSATION IN B/L FOOT AND HAMDS SINCE 4 DAYS

PAST HISTORY:

K/C/O HTN SINCE 4 MONTHS(TAB.ATENOLOL 25 MG PO/OD)

N/K/C/O T2DM,ASTHMA,CVA,CAV,TB

PERSONAL HISTORY: MARRIED, MIXED DIET, CONSTIPATION-PASSES HARD STOOLS ONCE

IN 3-4 DAYS,NON BLOOD TINGES,NORMAL MICTURITION, NO KNOWN ALLERGIES AND

ADDICTIONS

FAMILY HISTORY - NOT SIGNIFICANT

GENERAL EXAMINATION:

NO PALLOR , NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA,

MALNUTRITION

VITALS:- TEMP: AFEBRILE, BP: 160/80MMHG, RR: 16 CPM, PR: 104 BPM, SPO2: 97% AT RA,

GRBS-117MG%

SYSTEMIC EXAMINATION

CVS - S1 S2 + , NO MURMURS

RS - BAE + , NVBS

PER ABDOMEN : SOFT, NON TENDER, NO ORGANOMEGALY

CNS - NFND,GLASSGOW COMA SCALE E4V5M6

TONE

 RIGHT LEFT

UL NORMAL NORMAL

LL NORMAL NORMAL

POWER

 RIGHT LEFT

UL 5/5 5/5

LL 5/5 5/5

REFLEXES

 B T S K A

RIGHT +2 +1 +2 +2 +2

LEFT +2 +1 +2 +2 +2

COURSE :

PT CAME WITH COMPLAINT OFPEDAL EDEMA SINCE 10 DAYS, SHORTNESS OF BREATH

SINCE10 DAYS, INCIDENTAL FINDINGS IN ECG LIKE IRREGULAR RHYTHM, ABSENT P WAVES

WERE NOTED, SERIAL ECG WERE DONE, 2D ECHO WAS DONE , PT WAS DIAGNOSED

ASPAROXYSMAL ATRIAL FIBRILLATION WITHFAST VENTRICULAR RATE AND STARTED ON

MET-XL WAS GIVEN , PT WAS RESOLVED AND DISCHARGED IN HEMODYNAMICALLY

STABLE STATE

Investigation

LIVER FUNCTION TEST (LFT) 17-07-2025 Total Bilurubin 1.00 mg/dlDirect Bilurubin 0.20 mg/dl

SGOT(AST) 21 IU/L SGPT(ALT) 12 IU/L ALKALINE PHOSPHATASE 140 IU/L TOTAL PROTEINS

7.0 gm/dl ALBUMIN 4.0 gm/dlA/G RATIO 1.41

HEPATITIS- B SURFACE ANTIGEN (HBSAg) RAPID TEST 17-07-2025 06:24:PM NegativeANTI

HCV ANTIBODIES (Rapid Test)RAPID 17-07-2025 06:24:PM Non Reactive

COMPLETE URINE EXAMINATION (CUE) 17-07-2025 06:24:PMCOLOUR 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 Nil

HAEMOGLOBIN 13.6 gm/dl TOTAL COUNT 9600 cells/cummNEUTROPHILS 45% LYMPHOCYTES

45 %EOSINOPHILS 02%MONOCYTES 08%BASOPHILS 00 %PCV 36.9 vol %M C V 87.6 fl M C H

29.8 pg M C H C 36.6 % RDW-CV 12.6 % RDW-SD 40.9 fl

RBC COUNT 4.2 millions/cumm PLATELET COUNT 2.570 lakhs/cu.mm SMEARRBC Normocytic

normochromic WBC With in normal limits PLATELETS Adequate

RFT ProvisionalUREA 22 mg/dl CREATININE 0.8 mg/dlURIC ACID 2.9 mmol/L DHBSCALCIUM 9.8

mg/dl PHOSPHOROUS 2.6 mg/dlreductionSODIUM 135 mmol/L ElectrodePOTASSIUM 2.9

mmol/L.ElectrodeCHLORIDE 106 mmol/L

Treatment Given(Enter only Generic Name)

TAB.TELMA 40 MG PO/OD

TAB.LASIX 20 MG PO/BD(8AM-X-4PM)

SALT RESTRICTED DIET

BP MONITORING 4TH HOURLY

TAB.ECOSPORIN AV 75/20 MG PO/HS(X-X-9PM)

INJ.ANIODARONE 900MG IN 500ML NS

Advice at Discharge

TAB DYTOR 10MG MG PO/OD/8AM TO CONTINUE

TAB. MET-XL 50 MG PO/BD(8AM-X-8PM) TO CONTINUE

TAB DIBIGATRAN 150 MG PO/BD(8AM-X-8PM TO CONTINUE

TAB.CINOD 10 MG PO/OD 8AM-0-0 TO CONTINUE

SALT RESTRICTED DIET

Follow Up

REVIEW TO GM OPD AFTER 15 DAYS OR SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 35

62years/MALE

D. O. A : 19/07/2025

D. O. D : 21/07/2025

Diagnosis

HYPOGLYCEMIA SECONDARY TO ORAL HYPOGLYCEMIC DRUGS (RESOLVED)

HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF-42%)

PRERENAL ACUTE KIDNEY INJURY (RESOLVED ) ON CHRONIC KIDNEY DISEASE (STAGE 3B)

NON HEALING ULCER OVER DORSUM OF LEFT FOOT

K/C/O PERMANENT ATRIAL FIBRILLATION WITH FVR SINCE 2 YEARS

K/C/O OBSTRUCTIVE SLEEP APNEA SINCE 2 YRS

K/C/O OVERLAP SYNDROME

K/C/O DIABETES MELLITUS SINCE 1MONTH

K/C/O HYPERTENSION SINCE 1 YEAR

Case History and Clinical Findings

PATIENT CAME TO CASUALITY IN ALTERED SENSORIUM STATE SINCE MORNING

INSIDIOUS ONSET,ASSOCIZTED WITH PROFUSE SWATING ,DELAYED RESPONSE WHICH

WAS GRADUALLY PROGRESSIVE .

H/O TRAUMA TO LEFT FOOT DUE TO RTA 1 MONTH AGO FOR WHICH TREATMENT IS TAKEN

AT OUTSIDE HOSPITAL

AT THE TIME OF EVENT PT GRBS WAS 7MG/DL--SUGAR SYRUP WAS GIVEN --AT

PRESENTATION GRBS WAS 50MG/DL -INJ 25%DEXTROSE WAS CONNECTED

H/O PALPITATIONS +,SOB GRADE 3 +

NO H/O FEVER,COUGH,COLD,VOMITINGS,LOOSE STOOLS

NO H/O CHEST PAIN,PND

 NO H/O POLYURIA,POLYDYPSIA,BLURRING OF VISION,PAIN ABDOMEN,BURNING

MICTURITION,DECREASED URINE OUTPUT

PAST HISTORY :

K/C/O PERMANENT ATRIAL FIBRILLATION WITH FVR SINCE 2 YEARS

K/C/O OBSTRUCTIVE SLEEP APNEA SINCE 2 YRS

K/C/O OVERLAP SYNDROME

K/C/O HYPERTENSION SINCE 1 YEAR ON REGULAR MEDICATION

K/C/O DIABETES MELLITUS SINCE 1MONTH ON TAB.GLIMI M1 PO/BD

PERSONAL HISTORY: MARRIED, MIXED DIET, REGULAR BLADDER MOVEMENTS, BOWELSREGUAR, NO KNOWN ALLERGIES AND ALCOHOLIC +

FAMILY HISTORY - NOT SIGNIFICANT

GENERAL EXAMINATION: PEDAL EDEMA LEFT SIDE PITTING TYPE

NO PALLOR , ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY,MALNUTRITION

VITALS:- TEMP: 98.5 F, BP: 130/90MMHG, RR: 18 CPM, PR: 108 BPM, SPO2: 70% AT RA --

92%AT 5LIT O2, GRBS: 50 MG/DL---25%DEXTROSE ---130MG/DL

SYSTEMIC EXAMINATION

CVS , RS, PER ABDOMEN - NORMAL

CNS- GCS E4V5M6 ;NFND

COURSE IN THE HOSPITAL:

A 61 YEAR OLD MALE KNOWN DIABETIC,HYPERTENSION AND PERMANENT AF WITH

FVR,OSA CAME TO CASUALITY IN ALTERED SENSORIUM STATE ,H/O TRAUMA TO LT FOOT

,THOROUGH CLINICAL EXAMINATION WAS DONE WHICH SHOWED GRBS 50MG/DL

,INJ.25%DEXTROSE WAS CONNECTED FOLLOWING WHICH GRBS WAS 130MG/DL.ALL

NECESSARY INVESTIGATIONS WERE SENT ,ABG SHOWED PH-7.20,PCO2-43,PO2-45.3,HCO3-

16.3 AND RFT SHOWED BLOOD UREA -42,CREATININE -2.1 AND PATIENT IS PROVISIONALLY

DIAGNOSED AS HYPOGLYCEMIA SECONDARY TO OHAS,HF WITH MID RANGE EF,PRERENAL

AKI IN CKD ,ULCER OVER DORSUM OF LT FOOT.PATIENT IS TREATED WITH DEXTROSE

INFUSION,DIURETICS,ANTIBIOTICS,IVF,CCBS,BETA BLOCKERS. SERIAL ABG AND RFT

SHOWED IMPROVEMENT .REGULAR DRESSINGS WERE DONE.

PATIENT IMPROVED CLINICALLY AND NOW IS BEING DISCHARGED WITH STABLE VITALS.

Investigation

ANTI HCV ANTIBODIES (Rapid Test)RAPID 19-07-2025 Non Reactive

HEPATITIS- B SURFACE ANTIGEN (HBSAg) RAPID TEST 19-07-2025 Negative

HAEMOGLOBIN 12.2 gm/dl TOTAL COUNT 7,600 cells/cummNEUTROPHILS 91 %

LYMPHOCYTES 04 % EOSINOPHILS 01 %MONOCYTES 04 % BASOPHILS 00 %PCV 35.1 vol %

M C V 95.1 fl M C H 33.1 pg M C H C 34.8 %RDW-CV 15.7 % RDW-SD 56.7 fl RBC COUNT 3.69

millions/cumm PLATELET COUNT 2.51 lakhs/cu.mm SMEARRBC Normocytic normochromic Light

MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adequate in number and

distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light

MicroscopyIMPRESSION Normocytic normochromic blood

COMPLETE URINE EXAMINATION (CUE) 19-07-2025 COLOUR Pale yellowAPPEARANCE

ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS

NilPUS CELLS 2-4EPITHELIAL CELLS 1-2RED BLOOD CELLS NilCRYSTALS NilCASTS

NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

RFT 19-07-2025 UREA 42 mg/dlCREATININE 2.1 mg/dlURIC ACID 3.6 mmol/L CALCIUM 9.8

mg/dlPHOSPHOROUS 3.6 mg/dlSODIUM 136 mmol/LPOTASSIUM 4.6 mmol/L.CHLORIDE 101

mmol/L

Blood Lactate 18.0

FBS 80 mg/dl

Total Cholesterol 116 mg/dl Triglycerides 95 mg/dl HDL Choesterol 32.6 mg/dl LDL Cholesterol 74.8

mg/dl.VLDL * 11.0 mg/dl

LIVER FUNCTION TEST (LFT) 19-07-2025Total Bilurubin 0.52 mg/dlDirect Bilurubin 0.18 mg/dl

SGOT(AST) 13 IU/L SGPT(ALT) 10 IU/LALKALINE PHOSPHATASE 138 IU/LTOTAL PROTEINS 5.8

gm/dlALBUMIN 3.52 gm/dl A/G RATIO 1.54

THYROID PROFILE 19-07-2025 T3 0.49 ng/mlT4 8.72 micro g/dl TSH 3.21 micro Iu/ml

RFT 19-07-2025UREA 37 mg/dl CREATININE 2.4 mg/dl URIC ACID 4.4 mmol/LCALCIUM 10.0

mg/dlPHOSPHOROUS 2.4 mg/dl SODIUM 134 mmol/L POTASSIUM 5.2 mmol/L. CHLORIDE 96

mmol/L

Arterial Blood Gas Analysis (ABG) 19-07-2025 PH 7.32PCO2 35.7PO2 66.1HCO3 17.9St.HCO3

18.6BEB -7.0BEecf -7.1TCO2 37.9O2 Sat 91.6O2 Count 93.5

RFT 20-07-2025UREA 43 mg/dl 50-17 mg/dlCREATININE 1.9 mg/dlURIC ACID 4.5

mmol/LCALCIUM 10.0 mg/dlPHOSPHOROUS 3.0 mg/dlSODIUM 141 mmol/L POTASSIUM 4.0

mmol/L.CHLORIDE 102 mmol/L

Arterial Blood Gas Analysis (ABG) 20-07-2025 PH 7.351PCO2 42.4PO2 60.9HCO3 22.9St.HCO3

22.6BEB -2.1BEecf -1.9TCO2 47.4O2 Sat 91.6O2 Count 14.4

APTT TEST 34 Sec

Prothrombin Time 17 Sec INR 1.25

2DECHO WAS DONE ON 19/7/25 :VPCS DURING STUDY

GLOBAL HYPOKINESIA

RA,RV DILATED

LA,LV DIALTED

EF-46%

MILD TO MODERATE MR /TR WITH PAH

MILD LV DYSFUNCTION

GRADE 2 DIASTOLIC DYSFUNCTION

IVC-1.5CMS MILD DILATED,COLLAPSING

USG ABDOMEN AND PELIS WAS DONE 0N 19/7/25

NO SONOLOGICAL ABNORMALITY

BLOOD ,URINE AND SWAB CULTURES SENT :REPORTS AWAITED

Treatment Given(Enter only Generic Name)

INJ.25%DEXTROSE @30ML/HR INCREASED OR DECREASED ACCORDING TO GRBS

IVF NS @50ML/HR

INJ.PIPTAZ 4.5GM IV/STAT

INJ.PIPTAZ 2.25GM IV/QID -3DAYS

INJ.LINEZOLID 600MG IV/BD-3DAYS

INJ.PAN 40MG IV/OD

INJ.LASIX 40MG IV/BD

TAB.BISOPROLOL 5MG PO/OD

TAB.DILTIAZEM 30MG PO/BD

Advice at Discharge

TAB.AUGMENTIN 625MG PO/BD (1-0-1)X 5DAYS

TAB.LINEZOLID 600MG PO/BD (1-0-1)X 5DAYS

TAB.MET XL 50MG PO/OD (1-0-0) TO CONTINUE

TAB.DILTIAZEM 30MG PO/TID (1-1-1) TO CONTINUE

TAB.PAN 40MG PO/OD (1-0-0) BEFORE FOOD X 5DAYS

TAB.APIXABAN 5 MG PO/BD (1-0-1) TO CONTINUE

TAB.DYTOR PLUS 10/25 PO/OD (1-0-0) TO CONTINUE

TAB.CHYMEROL FORTE PO/TID (1-1-1) X 5DAYS

TAB.THIAMINE 100MG PO/OD (0-1-0) X 10DAYS

PLANNING TO START ANTI DIABETIC TREATMENT AFTER 3 DAYS

REGULAR DRESSING

Follow Up

REVIEW TO GM OPD AFTER 3 DAYS /SOS WITH CULTURE REPORTS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 36

70years/FEMALE

D. O. A : 19/03/2025

D. O. D : 24/03/2025

Diagnosis

HFmEF[EF:46%] OSA WITH CORPULMONALE

AKI ON CKD [STAGE 4] WITH HYPERKALEMIA [RESOLVED]

ATRIAL FLUTTER WITH CVR<---> VENTRICULAR BIGEMINY

ACUTE GASTRO ENTERITIS [RESOLVED]

K/C/O HYPERTENSION 2YEARS TYPE2 DIABETES MELLITUS 10MONTHS.

Case History and Clinical Findings

CHEIF COMPLAINTS: C/O LOOSE STOOLS SINCE 1 DAY

SOB SINCE 6 HRS

FEVER SINCE 1 DAY

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 DAY AGO THEN SHE DEVELOPED LOOSE

STOOLS WHICH IS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE WITH 3 TO 4 EPS

PER DAY NOT ASSOCAITED WITH NAUSEA , VOMITING, ABDOMINAL DISTENSION

PATIENT DEVELOPED SOB SINCE 6 HOURS WHICH IS GRADUALLY PROGRESSSIVE,

INSIDIOUS IN ONSET SOB GRADE 3 TO 4 ASSOCIATED WITH ORTHOPNEA, PND,

NO H/O FEVER , HEADACGE, CHEST PAIN, PALPITATION

NO SIMILAR COMPLAINTS IN THE PAST

PAST HISTORY:K/C/O T2 DM SINCE 10 MONTHS ON MEDICATION GLIMI M1 PO/OD

K/C/O HTN SINCE 2 YEARS ON TELMA 40MG PO/BD

N/K/C/O THYROID, CAD, EPILEPSY, ASTHMA, PULMO TB

GENERAL EXAMINATION:

PATIENT IS C/C/C

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

BP: 110/70 MM HG

PR: 90BPM

RR:22CPM

SPO2:98%

TEMP: AFEBRILE

SYSTEMIC EXAMINATION:

CVS: S 1 S 2 HEARD AND NO MURMURS

CNS: NFND

RS : BAE PRESENT

PA: SOFT AND NON TENDER

2D ECHO

CONCLUSION:

GLOBAL HYPOKINESIA ,MILD LVH ,POOR ECHOWINDOW

MODERATE MR +(ECCENTRIC MR+), MILD AR+, MODERATE TR+ WITH PAH(ECCENTRIC TR+)

,RVSP 48+10=58MMHG

NO AS/MS , SCLEROTIC AV,IAS INTACT ,EF =46%

MILD TO MODERATE LV DYSYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION ,NO LV CLOT,NO PE

IVC SIZE 1.79CMS DIALATED COLLAPSING

ALL CHAMBERS DIALATED

USG:GRADE 1 FATTY LIVER GRADE 1 RPD CHANGES IN LEFT KIDNEY

PSYCHIATRY REFFERAL WAS TAKEN IN VIEW OF IRRELAVENT TALKS AND IRRITABLE

BEHAVIOUR

ADVICED

TAB OLANZAPINE 2.5MG PO/OD AT 8PM

Investigation

Name Value Range

HAEMOGLOBIN 8.0 gm/dl 12.0 - 15.0 Colorimetric LOX -PAPTOTAL COUNT 10,500 cells/cumm

4000 - 10000 ImpedenceNEUTROPHILS 59 % 40 - 80 Light MicroscopyLYMPHOCYTES 21 % 20 -

40 Light MicroscopyEOSINOPHILS 04 % 01 - 06 Light MicroscopyMONOCYTES 16 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 24.0 vol % 36 - 46 CalculationM C V 88.6 fl

83 - 101 CalculationM C H 29.5 pg 27 - 32 CalculationM C H C 33.3 % 31.5 - 34.5 CalculationRDWCV 13.0 % 11.6 - 14.0 HistogramRDW-SD 42.9 fl 39.0-46.0 HistogramRBC COUNT 2.71

millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 2.21 lakhs/cu.mm 1.5-4.1

ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC monocytosis Light

MicroscopyPLATELETS Adeqaute Light MicroscopyHEMOPARASITES No hemoparasites seen Light

MicroscopyIMPRESSION Normocytic normochromic anemiawith monocytosis. Assay results should

be interpreted only in the context of otherName Value RangeRFT 19-03-2025 09:55:PMUREA 47

mg/dl 50-17 mg/dlCREATININE 2.3 mg/dl 1.2-0.6 mg/dlURIC ACID 6.5 mmol/L 6-2.6

mmol/LCALCIUM 9.2 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.4 mg/dl 4.5-2.5 mg/dlSODIUM 135

mmol/L 145-136 mmol/LPOTASSIUM 5.9 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 106 mmol/L 98-107

mmol/L

ABG 19-03-2025 09:55:PMPH 7.14PCO2 28.9PO2 54.8HCO3 9.5St.HCO3 10.5BEB -17.7BEecf -

17.7TCO2 22.2O2 Sat 87.9O2 Count 5.8LIVER FUNCTION TEST (LFT) 19-03-2025 09:55:PMTotal

Bilurubin 0.98 mg/dl 1-0 mg/dlDirect Bilurubin 0.20 mg/dl 0.2-0.0 mg/dlSGOT(AST) 29 IU/L 31-0

IU/LSGPT(ALT) 20 IU/L 34-0 IU/LALKALINE PHOSPHATASE 111 IU/L 128-56 IU/LTOTAL

PROTEINS 5.8 gm/dl 8.3-6.4 gm/dlALBUMIN 3.23 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.08

HBsAg-RAPID 19-03-2025 09:55:PM NegativeAnti HCV Antibodies - RAPID 19-03-2025 09:55:PM

Non Reactive

COMPLETE URINE EXAMINATION (CUE) 19-03-2025 09:55: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 NilABG 19-03-2025

09:57:PMPH 7.12PCO2 48.5PO2 71.3HCO3 15.1St.HCO3 14.1BEB -13.0BEecf -12.5TCO2 34.5O2

Sat 91.6O2 Count 9.9

ABG 20-03-2025 01:47:AMPH 7.01PCO2 20.6PO2 91.3HCO3 4.9St.HCO3 6.2BEB -23.7BEecf -

24.0TCO2 12.2O2 Sat 89.9O2 Count 3.2RFT 20-03-2025 01:49:AMUREA 46 mg/dl 50-17

mg/dlCREATININE 2.4 mg/dl 1.2-0.6 mg/dlURIC ACID 6.3 mmol/L 6-2.6 mmol/LCALCIUM 9.4 mg/dl

10.2-8.6 mg/dlPHOSPHOROUS 4.4 mg/dl 4.5-2.5 mg/dlSODIUM 138 mmol/L 145-136

mmol/LPOTASSIUM 5.2 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 104 mmol/L 98-107 mmol/L

T3, T4, TSH 20-03-2025 01:49:AMT3 0.79 ng/ml 1.87-0.87 ng/mlT4 10.40 micro g/dl 12.23-6.32

micro g/dlTSH 4.16 micro Iu/ml 5.36-0.34 micro Iu/mlABG 20-03-2025 01:27:PMPH 7.13PCO2

48.9PO2 62.3HCO3 15.9St.HCO3 14.8BEB -11.9BEecf -11.5TCO2 36.2O2 Sat 88.7O2 Count 9.4

RFT 20-03-2025 11:17:PMUREA 30 mg/dl 50-17 mg/dlCREATININE 1.9 mg/dl 1.2-0.6 mg/dlURIC

ACID 6.1 mmol/L 6-2.6 mmol/LCALCIUM 9.9 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.3 mg/dl 4.5-2.5

mg/dlSODIUM 141 mmol/L 145-136 mmol/LPOTASSIUM 4.9 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

107 mmol/L 98-107 mmol/LABG 20-03-2025 11:17:PMPH 7.21PCO2 42.0PO2 53.6HCO3

16.2St.HCO3 15.9BEB -10.5BEecf -10.2TCO2 35.8O2 Sat 85.3O2 Count 10.3

SERUM ELECTROLYTES (Na, K, C l) 21-03-2025 06:20:PMSODIUM 136 mmol/L 145-136

mmol/LPOTASSIUM 5.3 mmol/L 5.1-3.5 mmol/LCHLORIDE 102 mmol/L 98-107 mmol/LRFT 22-03-

2025 01:22:AMUREA 32 mg/dl 50-17 mg/dlCREATININE 1.8 mg/dl 1.2-0.6 mg/dlURIC ACID 6.5

mmol/L 6-2.6 mmol/LCALCIUM 9.7 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.0 mg/dl 4.5-2.5

mg/dlSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 4.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

102 mmol/L 98-107 mmol/L

USG:GRADE 1 FATTY LIVER GRADE 1 RPD CHANGES IN LEFT KIDNEY

Treatment Given(Enter only Generic Name)

1. IV FLUIDS NS AND DNS @ 75ML/HR

2. INJ.MONOCEF 1GM IV/BD

3. INJ . DOXYCYCLINE 100MG IV/BD

4.INJ PAN 40MG IV/OD

5. INJ 25% D WITH 8U HAI IV /TID

6. INJ LASIX 40MG IV/BD

7. TAB TELAM 40 PO/OD

8.TAB MET XL 50MG PO/OD

9. TAB DABIGATRAN 110MH PO/BD

10. TAB DAPA 10MG BFR LUNCH

11. TAB ROSUVAS CV 75/10 PO/HS

12. TAB NEFROSAVE PO/BD

13. TAB OROFER XT PO/OD

14. TAB SHELCAL XT PO/OD

15. K BINDER SACHETS IN 1LT WATER/TID

16 INJ EPO 4000IV / SC ON ALTERNATE DAYS

17. I/O MONITORING

18. TAB OLANZAPINE 2.5MG PO/BD

19.TAB NODOSIS 1GM PO/TID

20. TAB ISTAMET 50/500 OD

COURSE IN THE HOSPITAL

 70 YEAR OLD FEMALE KNOWN DIABETIC AND HYPERTENSIVE CAME WITH C/O LOOSE

STOOLS SINCE 1 DAY FEVER 1 DAY VITALS AT PRESENTATION AFEBRILE BP:110/70,

PR:90BPM, RR:22CPM, SPO2:76@RA GRBS:75 ECG SHOWED AF WITH CVR ABG SHOWED

SEVERE METABOLIC ACIDOSIS [HAGMA] AND ALL NECESSARY INVESTIGATIONS HAVE

BEEN SENT DIAGNOSED AS HFmEF[EF:46%] OSA WITH CORPULMONALE,AKI ON CKD

[STAGE 4] WITH HYPERKALEMIA,ATRIAL FLUTTER WITH CVR<---> VENTRICULAR

BIGEMINY,ACUTE GASTRO ENTERITIS TREATED WITH C PAP SUPPORT, ANTIBIOTICS, IV

FLUIDS, DIURETICS, BETABLOCKERS, ANTICOAGULANTS, ANTIPLATELETS, HYPERKALEMIA

CORRECTION WERE DONE. PATIENT WAS IRRITABLE FROM DAY 2 OF ADMISSION

PSYCHIATRY REFFERAL WAS TAKEN AND ADVICED ANTIPSYCHOTICS[OLANZEPINE]

HYPERKALEMIA WAS RESOLVED AND PATIENT SENSORIUM WAS IMPROVED,PATIENT WAS

IMPROVED CLINICALLY AND DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION.

Advice at Discharge

TAB ISOLAZINE 20/37.5 PO/TID TO BE CONTINUED

TAB MET XL 50MG PO/OD AT 8AM TO BE CONTINUED

TAB DABIGATRAN 110MG PO/BD TO CONTINUE

TAB DYTOR 10MG PO/OD AT 8AM TO BE CONTINUED

TAB DAPA 10MG PO/OD BEFORE LUNCH

TAB ISTAMET 50/500 OD TO BE CONTINUED

TAB ROSUVAS CV 75/10 PO/HS AT 9PM TO BE CONTINUED

TAB NEFROSAVE PO/BD TO CONTINUE

TAB OROFER XT PO/OD FOR 30 DAYS

TAB SHELCAL XT PO/OD FOR 30 DAYS

TAB OLANZAPINE 2.5MG PO/BD

INJ EPO 4000IV / SC ON ALTERNATE DAYS TO BE CONTINUE

TAB NODOSIS 1GM PO/BD TO BE CONTINUED

TAB.MAGRIUM 400MG PO/OD 1WEEK

Follow Up

REVIEW TO GM OPD AFTER 5DAYS ON FRIDAY 28/03/2025

REVIEW TO PSYCHIATRY OPD AFTER 1 WEEK OR SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 37

50years/MALE

D. O. A : 30/12/2024

D. O. D : 03/01/2025

Diagnosis

HEART FAILURE WITH REDUCED EJECTION FRACTION (25%) , ATRIAL FIBRILLATION WITH

FVR

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

K/C/O DM-II SINCE 3 YEARS, K/C/O HTN SINCE 6 MONTHS

Case History and Clinical Findings

CHIEF COMPLAINTS

C/O SHORTNESS OF BREATH SINCE 1 MONTH

SWELLING OF BOTH LOWER LIMBS SINCE 10 DAYS

COUGH SINCE 1 MONTH

HISTORY OF PRESENT ILLNESS

PATIENT WAS APPARENTLY ASYMPTOMATIC BEFORE 1 MONTH, GRADUALLY HAD SOB

WITH MINIMAL EXERTION ( GR-II NYHA). PND PRESENT, ORTHOPNEA PRESENT. SWELLING

OF BOTH LOWER LIMBS (GR-IV) PITTING TYPE PEDAL EDEMA GRADUALLY PROGRESSIVE.

COUGH SINCE 1 MONTH WITH THICK MUCOID SPUTUM. NO H/O FEVER, VOMITINGS,

DIARRHEA, BURNING MICTURITION.

PAST HISTORY

K/C/O DM-II SINCE 3 YEARS

K/C/O HTN SINCE 6 MONTHS

PERSONAL HISTORY

APETTITE-LOST

DIET-MIXED

 BOWELS-IRREGULAR

MICTURITION-ABNORMAL

ALLERGIES-NIL

ADDICTIONS - REGULAR ALCOHOLIC

GENERAL EXAMINATION :

PATIENT IS C/C/C

GRADE IV PITTING TYPE PEDAL EDEMA PRESENT

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHEDENOPATHY

BP: 140/80 MMHG

PR: 138 BPM

RR: 26 CPM

SPO2: 97% AT RA

GRBS: 156 MG/DL

SYSTEMIC EXAMINATION :

CVS: S1S2+,NO MURMURS

JVP RAISED, APEX- LATERAL TO MID CLAVICULAR LINE

RS: DECREASED BAE, B/L DIFFUSE CREPTS PRESENT, WHEEZE PRESENT

P/A: SOFT, DISTENDED,NO ORGANOMEGALY

NO SCARS, SINUSES

NO ENGORGED VEINS

UMBILICUS EVERTED

CNS: HIGHER MENTAL FITNESS - NORMAL

MEMORY - GOOD

SPEECH - NORMAL

MOTOR SYSTEM

 RIGHT LEFT

TONE UL N N

 LL N N

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

REFLEXES BICEPS +2 +2

 TRICEPS +1 +1

 SUPINATOE +1 +1

KNEE +2 +2

 ANKLE +1 +1

 PATELLAR E E

CARDIOLOGY REFERRAL

ADVICE : T. ONARNI 1/2 BD

HIGH PROTEIN DIET

T. SPIRONOLACTONE

T. APIXABAN 2.5MG PO/BD

Investigation

NameValueRangeNameValueRangeCOMPLETE URINE EXAMINATION (CUE) 30-12-2024

10:57:PM COLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN++SUGARNilBILE

SALTSNilBILE PIGMENTSNilPUS CELLS3-4EPITHELIAL CELLS2-3RED BLOOD

CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilLIVER FUNCTION

TEST (LFT) 30-12-2024 10:57:PM Total Bilurubin1.43 mg/dl1-0 mg/dlDirect Bilurubin0.39 mg/dl0.2-

0.0 mg/dlSGOT(AST)35 IU/L35-0 IU/LSGPT(ALT)58 IU/L45-0 IU/LALKALINE PHOSPHATASE217

IU/L128-53 IU/LTOTAL PROTEINS5.8 gm/dl8.3-6.4 gm/dlALBUMIN3.36 gm/dl5.2-3.5 gm/dlA/G

RATIO1.38BLOOD UREA30-12-2024 10:57:PM82 mg/dl42-12 mg/dlSERUM CREATININE30-12-

2024 10:57:PM1.4 mg/dl1.3-0.9 mg/dlSERUM ELECTROLYTES (Na, K, C l) 30-12-2024 10:57:PM

SODIUM139 mmol/L145-136 mmol/LPOTASSIUM4.5 mmol/L5.1-3.5 mmol/LCHLORIDE104

mmol/L98-107 mmol/LBLOOD UREA31-12-2024 11:41:PM68 mg/dl42-12 mg/dlSERUM

CREATININE31-12-2024 11:41:PM1.2 mg/dl1.3-0.9 mg/dlSERUM ELECTROLYTES (Na, K, C l) 31-

12-2024 11:41:PM SODIUM138 mmol/L145-136 mmol/LPOTASSIUM3.5 mmol/L5.1-3.5

mmol/LCHLORIDE98 mmol/L98-107 mmol/LBLOOD UREA01-01-2025 11:53:PM47 mg/dl42-12

mg/dlSERUM CREATININE01-01-2025 11:53:PM1.0 mg/dl1.3-0.9 mg/dlSERUM ELECTROLYTES

(Na, K, C l) 01-01-2025 11:53:PM SODIUM137 mmol/L145-136 mmol/LPOTASSIUM3.4 mmol/L5.1-

3.5 mmol/LCHLORIDE101 mmol/L98-107 mmol/L

RBS- 82MG/DL

HEMOGRAM ON 30/12/24

HAEMOGLOBIN 15.3 GM/DL

TOTAL COUNT 10,000 CELLS/CUMM

NEUTROPHILS 67%

LYMPHOCYTES 25%

EOSINOPHILS 01%

MONOCYTES 07%

BASOPHILS 0%

PCV 44.5 VOL%

MCV 87.1 FL

MCH 29.9 PG

MCHC 34.3%

RDW-CV 15.1%

RDW-SD 50.2FL

RBC COUNT 5.11 MILLIONS/CUMM

PLATELET COUNT 1.77 LAKHS/CUMM

SMEAR

RBC NORMOCYTIC NORMOCHROMIC

WBC WITHIN NORMAL LIMITS

PLATELETS ADEQUATE IN NUMBER AND DISTRIBUTION

HEMOPARASITES NOT SEEN

IMPRESSION NORMOCYTIC NORMOCHROMIC

2D ECHO

IMPRESSION : SEVERE TR+ WITH MILD PAH; MILD MR+ ; MILD AR+/PR+

RMWA+ LAD AKINETIC, RCA AND LCX HYPOKINETIC ; NO AS/MS

SEVERE LV DYSFUNCTION PRESENT

GRADE IV DIASTOLIC DYSFUNCTION+ ; NO LV CLOT

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <2G/DAY

SALT RESTRICTION <1.5/DAY

HIGH PROTIEN DIET - 2 EGG WHITES PER DAY

INJ. AUGMENTIN 1.2GM/DAY

TAB. MET XL 25MG/DAY

CAP. ECOSPRIN AV 75/20 PO/HS

TAB.ONARNI 100MG 1/2 PO/BD

TAB. SPIRONOLACTONE 25MG PO/BD

TAB. APIXABAN 2.5MG PO/BD

TAB. METFORMIN 500MG PO/OD

TAB. PAN 40MG PO/OD

NEBS WITH BUDECORT 8TH HOURLY

 IPRAVENT 8TH HOURLY

TAB. DAPAGLIFOZIN 100MG PO/OD

Advice at Discharge

FLUID RESTRICTION <2G/DAY

SALT RESTRICTION <1.5/DAY

HIGH PROTIEN DIET - 2 EGG WHITES PER DAY

TAB. MET XL 25MG PO/BD

TAB. SPIRONOLACTONE 25MG 1/2 PO/BD

TAB. APIXABAN 2.5MG PO/BD

TAB. METFORMIN 500MG PO/BD

TAB. PAN 40MG PO/OD

NEBS WITH BUDECORT 8TH HOURLY

 IPRAVENT 8TH HOURLY

TAB. DAPAGLIFOZIN 10MG PO/OD,

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language

CASE NO : 38

75years/MALE

D. O. A : 28/02/2025

D. O. D : 10/03/2025

Diagnosis

ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE

HEART FAILURE WITH PRESERVED EJECTION FRACTION 62%

FRACTURE OF SPINOUS PROCESS OF TRANSVERSE PROCESS AT DORSAL AND UPPER

LUMBAR LEVEL SECONDARY TO RTA

Case History and Clinical Findings

CAME WITH A/H/O RTA BIKE HIT BY CAR

HOPI:

PATIENT WAS A/H/O RTA BIKE HIT BY CAR AT AROUND 6:45PM ON 28/2/25 ,

HEAD INJURY PRESENT ABDOMEN TENDERNESS PRESENT

C/O ABDOMINAL PAIN BACK ACHE

NO H/O LOC,ENT BLEED ,VOMITINGS LOOSE STOOLS

NO H/O FEVER

PAST HISTORY:

K/C/O DM, HTN ON MEDICATIONB

N/K/C/O, THYROID, EPILEPSY, CVA, CAD, CKD

O/E, A 3X3 CM GRAZED ABRASION OVER LEFT ELBOW, A 3X3 CM GRAZED ABRASION OVER

OCCIPITAL AREA , MULTIPLE GRAZED ABRASION OVER FACE AND RIGHT ARM

LOCAL EXAMINATION OF SPINENO VISIBLE DEFORMITY, SKIN -NORMAL

SWELLING- MILD OVER THORACOLUMBAR REGION

NO LOCAL RISE OF TEMPERATURE

TENDERNESS- PRESENT OVER D8 TO D12 AND L3 TO S1 LEVEL IN MIDLINE AND

PARASPINAL AREA

ROM- RESTRICTED AND PAINFULL

CASE SEEN BY GM ON 5/3/25

H/O GIDDINESS PRESENT WHEN GETTING UP FROM SUPINE TO SITTING POSITION

NO H/O CHEST PAIN PALPITATION, BREATHLESNESS, ORTHOPNEA NO H/O

NOCTURIA,POLYURIA,POLYPHAGIA,POLYDYPSIA

NO H/O FEVER COLD COUGH

K/C/O DM T2 SINCE 5 YEARS ON MEDICATION TAB METFORMIN 500MG OD

K/C/O HTN SINCE 5 YEARS ON MEDICATION TAB AMLODIPINE 5MG OD

N/K/C/O, THYROID, EPILEPSY, CVA, CAD, CKD

DIAGNOSED AS AF WITH FVR HEART FAILURE WITH PRESERVED EJECTION FRACTION

TYPE 2 DM /HTN

FRACTURE OF SPINOUS PROCESS OF TRANSVERSE PROCESS AT LOWER DORSAL AND

UPPER LUMBAR LEVEL SECONDARY TO RTA

PATIENT IS C/C/C

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY

TEMP- AFEBRILE

PULSE RATE-86 BPM

BP-140/90 MM HG

SPO2-97 % @ RA

GRBS-

8AM -173,10AM- 180, 2PM- 200, 4PM-241, 7PM- 174, 10PM-205, 2AM-184

SYSTEMIC EXAMINATION:

CVS: S1S2+, NO MURMURS

RS: BAE+, NVBS

P/A: SOFT, NO N TENDER, BOWEL SOUNDS+

CNS: NFND

GS REFERRAL DONE ON 1/3/25 I/V/O RETROPERITONEAL HEMORRHAGE ON RIGHT SIDE

EXTENDING INTO PARASPINAL MUSCLES

ADVICED USG ABDOMEN AND PELVIS I/V/O SIZE OF RETROPERITONEAL HEMORRHAGE

CASE TRANSFEREED TO GM ON 6/3/25

Investigation

HBsAg-RAPID 01-03-2025 05:17:PM Negative

Anti HCV Antibodies - Non ReactiveCOMPLETE BLOOD PICTURE (CBP) 01-03-2025

HAEMOGLOBIN 10.9 gm/dl TOTAL COUNT 10800 cells/cummNEUTROPHILS 76 %

LYMPHOCYTES 14 %EOSINOPHILS 01 % MONOCYTES 09 % BASOPHILS 00 % PLATELET

COUNT 1.83SMEAR Normocytic normochromic anemia

COMPLETE URINE EXAMINATION (CUE) 01-03-2025 05:17:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN traceSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-4RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilRFT 01-03-2025

05:17:PMUREA 27 mg/dl 50-17 mg/dlCREATININE 1.0 mg/dl 1.3-0.8 mg/dlURIC ACID 4.1 mmol/L

7.2-3.5 mmol/LCALCIUM 9.8 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.1 mg/dl 4.5-2.5 mg/dlSODIUM

138 mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 98 mmol/L 98-107

mmol/L

LIVER FUNCTION TEST (LFT) 01-03-2025 05:17:PMTotal Bilurubin 1.76 mg/dl 1-0 mg/dlDirect

Bilurubin 0.50 mg/dl 0.2-0.0 mg/dlSGOT(AST) 119 IU/L 35-0 IU/LSGPT(ALT) 137 IU/L 45-0

IU/LALKALINE PHOSPHATASE 88 IU/L 128-56 IU/LTOTAL PROTEINS 6.2 gm/dl 8.3-6.4

gm/dlALBUMIN 3.9 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.72

POST LUNCH BLOOD SUGAR 05-03-2025 07:45:AM 155 mg/dl 140-0 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 06-03-2025 11:37:PMSODIUM 139 mmol/L 145-136

mmol/LPOTASSIUM 4.0 mmol/L 5.1-3.5 mmol/LCHLORIDE 101 mmol/L 98-107

mmol/LPHOSPHOROUS 06-03-2025 11:37:PM 3.1 mg/dl 4.5-2.5 mg/dl

T3, T4, TSH 06-03-2025 11:37:PMT3 0.91 ng/ml 1.87-0.87 ng/mlT4 13.60 micro g/dl 12.23-6.32

micro g/dlTSH 2.76 micro Iu/ml 5.36-0.34 micro Iu/mlSERUM ELECTROLYTES (Na, K, C l) 07-03-

2025 11:06:PMSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.9 mmol/L 5.1-3.5

mmol/LCHLORIDE 101 mmol/L 98-107 mmol/L

BLOOD UREA 08-03-2025 26 MG/DLSERUM CREATININE 08-03-2025 0.9 mg/dl

EFAST DONE ON 28/2/25

NEGATIVE EFAST

2D ECHO DONE ON 5/3/25

AF DURING STUDY

LEFT ATRIUM 3.9CM MILD DILATED, MITAL WALL THICKENED

IVC SIZE 0.7 CM COLLAPSING , EF 62%

MILD TO MODERATE TR WITH PH, MILD MR/AR TRIVIAL PR

CONCENTRIC LVH NO RWMA

GOODLV SYSTOLOC FUNCTION, GRADE 2 DIASTOLIC DYFUNCTION NO PE/NO LV CLOT

Treatment Given(Enter only Generic Name)

INJ. MET XL 5MG IV/SOS

TAB METOPROLOL TARTARATE 50MG PO/BD

TAB DABIGO 110MG PO/BD

TAB TELMA 20MG PO/OD

TAB METFORMIN 500MG PO/BD

TAB XYKAA 1GM PO/OD

TAB PAN 40MG PO/OD

TAB SHELCAL CT PO/OD

TAB LIMCEE 500MG PO/OD

GRBS 7 POINT PROFILE

Advice at Discharge

TAB METOPROLOL TARTARATE 50MG PO/BD TO CONTINUE

TAB DABIGO 110MG PO/BD TO CONTINUE

TAB TELMA 20MG PO/OD TO CONTINUE

TAB METFORMIN 500MG PO/BD TO CONTINUE

TAB XYKAA 1GM PO/OD FOR 15 DAYS

TAB SHELCAL CT PO/OD FOR 15 DAYS

TAB LIMCEE 500MG PO/OD FOR 7 DAYS

Follow Up

REVIEW TO GM OPD AFTER 1 WEEK WITH ECG AND SERUM ELECTROLYTES REPORT OR

SOS

REVIEW TO ORTHOPEDICS OPD AFTER 2WEEKS OR SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 39

81years/MALE

D. O. A : 01/03/2026

D. O. D : 08/03/2025

Diagnosis

PERSISTENT AF WITH FVR

HF WITH PRESERVED EF (55%)

COPD, DE NOVO TYPE 2 DM (HBA1C-6.5)

URINARY BLADDER CALCULUS

Case History and Clinical Findings

C/O BREATHLESSNESS SINCE 7 DAYS

C/O BURNING MICTURIOTION SINCE 7 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 4 MONTHS BACK THEN DEVELOPED BURNING

MICTURITION, FEVER, BREATHLESNESS ADMITTED IN OUR HOSPITAL, DIAGNOSED WITH

RIGHT LOWER LIMB CELLULITIS WITH BLADDER CALCULI AND SYMPTOMS GOT SUBSIDED.

NOW DEVELOPED BURNING MICTURITION SINCE 7 DAYS, BREATHLESNESSGRADE II SINCE

3 MONTHS ON AND OFF, AGGRAVATED SINCE PAST 7 DAYS ASSOCIATED WITH

PALPITATIONS

H/O PEDAL EDEMA ON AND OFF, H/O LOW GRADE FEVER SINCE 3 DAYS

NO H/O PAIN ABDOMEN, VOMITINGS, LOOSE STOOLS, GIDDINESS, SWEATING, COUGH,

COLD.

PAST HISTORY:

K/C/O AF WITH CVR NOT USING MEDICATION

N/K/C/O T2DM,HTN, CVA, CAD, THYROID DISORDER, ASTHMA, SEIZURE DISORDER

PERSONAL HISTORY:

DIET-MIXED

APPETITE- NORMAL

BOWEL MOVEMENTS- REGULAR

BLADDER- NORMAL

SLEEP- ADEQUATE

ADDICTIONS: NIL

FAMILY HISTORY : NOT SIGNIFICANT

GENERAL EXAMINATION:

PATIENT IS C/C/C

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA

TEMP: 98.4F

BP:100/70MMHG

PR:116BPM

RR:17CPM

SPO2: 86% AT RA

GRBS :136MG/DL

SYSTEMIC EXAMINATION:

CVS:S1 S2 HEARD ,NO MURMURS

RS:BAE +,NVBS HEARD

PA:SOFT,NON TENDER

CNS:NFND

GCS: E4V5M6

 RT LT

TONE UL NORMAL NORMAL

 LL NORMAL NORMAL

POWER UL 4/5 4/5

 LL 4/5 4/5

REFLEXES B 2+ 2+

 T 2+ 2+

 S 1+ 1+

 K 2+ 2+

 A 1+ 1+

 P F F

Investigation

NameValueRangeNameValueRangeRFT 01-03-2025 08:40:PM UREA41 mg/dl50-17

mg/dlCREATININE1.1 mg/dl1.3-0.8 mg/dlURIC ACID5.4 mmol/L7.2-3.5 mmol/LCALCIUM9.7

mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.0 mg/dl4.5-2.5 mg/dlSODIUM138 mmol/L145-136

mmol/LPOTASSIUM3.8 mmol/L.5.1-3.5 mmol/L.CHLORIDE98 mmol/L98-107 mmol/LLIVER

FUNCTION TEST (LFT) 01-03-2025 08:40:PM Total Bilurubin1.17 mg/dl1-0 mg/dlDirect Bilurubin0.30

mg/dl0.2-0.0 mg/dlSGOT(AST)19 IU/L35-0 IU/LSGPT(ALT)11 IU/L45-0 IU/LALKALINE

PHOSPHATASE140 IU/L128-56 IU/LTOTAL PROTEINS6.5 gm/dl8.3-6.4 gm/dlALBUMIN3.84

gm/dl4.6-3.2 gm/dlA/G RATIO1.44COMPLETE URINE EXAMINATION (CUE) 01-03-2025 08:40:PM

COLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN+SUGAR+++BILE

SALTSNilBILE PIGMENTSNilPUS CELLS3-6EPITHELIAL CELLS2-4RED BLOOD

CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilHBsAg-RAPID01-

03-2025 08:40:PMNegative Anti HCV Antibodies - RAPID01-03-2025 08:40:PMNon Reactive

COMPLETE URINE EXAMINATION (CUE) 07-03-2025 08:27:AM COLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN+SUGARNilBILE

SALTSNilBILE PIGMENTSNilPUS CELLS2-4EPITHELIAL CELLS2-3RED BLOOD

CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNil

HEMOGRAM 01-03-25

HAEMOGLOBIN 12.0 G/DLTOTAL COUNT 5,100 CELLS/CU.MM NEUTROPHILS 85 %

LYMPHOCYTES 11 % EOSINOPHILS 01 % MONOCYTES 03% BASOPHILS 00 % PCV 35.5 VOL

% M C V 91.7 FLM C H 30.9 PGM C H C 33.7 %RDW-CV 12.5 % RDW-SD 43.9 FLRBC COUNT

3.87 MILLIONS/CU.MMPLATELET COUNT 1.64 LAKHS/CU.MMSMEARRBC NORMOCYTIC

NORMOCHROMICWBC WITHIN NORMAL LIMITS WITH NEUTROPHILIAPLATELETS

ADEQUATEHEMOPARASITES NO HAEMOPARASITES SEENIMPRESSION NORMOCYTIC

NORMOCHROMIC WITH NEUTROPHILIA

APTT 01-03-25: 33 SEC

BT, CT ON 01-03-25:

BT: 2MIN 30 SEC

CT: 5MIN 00 SEC

RBS 01-03-25: 180MG/DL

PT 01-03-25: 17 SEC

INR 01-03-25: 1.2

FBS 02-03-25 :88 MG/DL

HbA1c ON 02-03-25 :6.5 %

LIPID PROFILE 03-03-25

TOTAL CHOLESTEROL 159 MG/DL TRIGLUCERIDES 88MG/DL HDLCHOLESTEROL 38.8

MG/DLLDL CHOLESTEROL107.7 MG/DLVLDL * 17.6 MG/DL

BGT 06-01-25: B POSITIVE

HEMOGRAM 07-03-25

HAEMOGLOBIN 12.1 G/DLTOTAL COUNT 7,800 CELLS/CU.MM NEUTROPHILS 66 %

LYMPHOCYTES 22 % EOSINOPHILS 02 % MONOCYTES 10% BASOPHILS 00 % PCV 33.9 VOL

% M C V 92.6 FLM C H 33.1 PGM C H C 35.7 %RDW-CV 12.3 % RDW-SD 42.3 FLRBC COUNT

3.66 MILLIONS/CU.MMPLATELET COUNT 1.72 LAKHS/CU.MMSMEARRBC NORMOCYTIC

NORMOCHROMICWBC WITHIN NORMAL LIMITS PLATELETS ADEQUATEHEMOPARASITES NO

HAEMOPARASITES SEENIMPRESSION NORMOCYTIC NORMOCHROMIC BLOOD PICTURE

USG KUB DONE ON 01-03-25

IMPRESSION: URINARY BLADDER CALCULUS

RAISED ECHOGENESITY OF LEFT KIDNEY WITH B/L RENAL CORTICAL CYSTS

UROLOGY REFERRAL DONE ON 04-03-25

ADVICE:

CATHETERIZE PATIENT WITH 16FR FOLEY'S

USG KUB REVIEW FOR PROSTATE SIZE

CARDIOLOGY OPINION

TAB. NORFLOX PO/BD

TAB. PAN 40MG PO/OD

TAB.TAMSULOSIN 0.4MG PO/HS

SYP. CRANPAC KM 15ML BD

USG KUB DONE ON 05-03-25

IMPRESSION: URINAR BLADDER CALCULI, B/L RENAL CORTICAL CYSTS

2D ECHO DONE ON 03-03-25

IMPRESSION: MODERATE TR+ WITH PAH, MILD AR+, TRIVIAL MR+

PARADOXICAL IVS. MILD LVH+, NO AS/MS

FAIR TO GOOD LV SYSTOLIC FUNCTION

GRADE II DIASTOLIC DYSFUNCTION+; NO PE/LV CLOT

CARDIOLOGY REFERRAL DOONE ON 05-03-25

ADVICE:

HIGH RISK FOR SURGERY

STOP REMIPRIL, DIGABATRIN 2 DAYS BEFORE SURGERY

CONTINUE DYTOR 10M, MET XL 25MG

DVT PROPHYLAXIS WITH CLEXANE

Treatment Given(Enter only Generic Name)

TAB. DYTOR 10MG PO/OD

TAB. PCM 650MG PO/SOS

NEB. WITH BUDECORT 8TH HOURLY

SYP. CREMAFFIN 15ML PO/HS

TAB. TAMSULOSIN 0.4MG PO/HS

TAB. NORFLOX 200MG PO/BD

SYP. CRANPAC 15ML PO/BD

TAB. METFORMIN 500MG PO/OD AFTER BREAKFAST

IVF NS 500ML BOLUS/STAT

TAB. RAMIPRIL 2.5 MG PO/OD

TAB. DIGABATRIN 110 MG PO/BD

Advice at Discharge

TAB. DYTOR 5 MG PO/OD TO CONTINUE

TAB. PCM 650MG PO/SOS

SYP. CREMAFFIN 15ML PO/HS TO CONTINUE

TAB. TAMSULOSIN 0.4MG PO/HS TO CONTINUE

TAB. NORFLOX 200MG PO/BD X 3 DAYS

SYP. CRANPAC 15ML PO/BD TO CONTINUE

TAB. METFORMIN 500MG PO/OD AFTER BREAKFAST TO CONTINUE

TAB. RAMIPRIL 2.5 MG PO/ODTO CONTINUE

TAB. DIGABATRIN110 MG PO/BD TO CONTINUE

PATIENT DISCHARGED WITH FOLEY'S CATHETER

Follow Up

REVIEW TO UROLOGY OPD AFTER 3 WEEKS/SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

 AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 40

75years/MALE

D. O. A : 05/01/2025

D. O. D : 10/01/2025

Diagnosis

ACUTE CVA SECONDARY TO ISCHAEMIC STROKE LT CEREBELLAR REGION

ATRIAL FIBRILLATION WITH FVR -NORMAL SNUS RYTHM

K/C/O COPD SINCE 10 YEARS

K/C/O HTN SINCE 5 YEARS

Case History and Clinical Findings

PATENT WAS BROUGHT TO CASUALTY WITH C/O SLURRING OF SPECH SINCE 2 HRS

PATIENT WAS APPARANTLY ASYMPTOMATIC SINCE 2 HRS AGO AND THEN HE DEVELOPED

SLURRING OF SPEECH SINCE 2 HRS, WHILE TALKING DEVIATION OF MOUTH TO LEFT SIDE ,

WEAKNESS OF ALL LIMBS , NO H/O INVOLUNTARY MOVEMENTS , UPROLLING OF EYES ,

FROTHING FROM MOUTH , INVOLUNTARY DEFECATION AND MICTURITION

A/H/O FALL AT A TREE AND UNABLE TO GET UP AND ATTENDERS HAVE LIFTED NOT ASS

WITH LOC AND ANY INJURY TO HEAD .

NO H/O FEVER, COLD, COUGH, ALLERGIES, CHEST PAIN, PALPITATIONS, SWEATING , SOB,

ABDOMINAL PAIN , NAUSEA

,VOMITING , LOOSE STOOLS , BURNING MICTURITION, CONSTIPATION , PEDAL EDEMA

PAST H/O

K/C/O BRONCHIAL ASTHMA AND ON INHALER

K/C/O OF HTN SINCE 10 YRS AND ON UNKNOWN REGULAR MEDICATION

NOT A K/C/O DM, TB , EPILEPSY, CVA ,CAD

FAMILY H/O SEIZURE DISORDER FOR FATHER , GRANDFATHER,AUNT

GENERAL EXAMINATION

PATIENT IS C/C/C

NO PALLOR,ICTERUS, CYNOSIS, CLUDDING, LYMPHADENOPATHY

BP: 130/90 MMHG

PR: 90 BPM

RR: 18 CPM

SPO2: 96% AT RA

GRBS -107 MG/DL

SYSTEMIC EXAMINATION :

CVS: S1S2+, NO MURMURS

NO JVP RAISED

RS: BAE+,NVBS +,NO ADDED SOUNDS

CNS

POWER RT LT

 UL 4/5 4/5

 LL 4/5 2/5

TONE RT LT

 UL N INCREASD

 LL N INCREASED

Investigation

HB - 13.6

TC-16100

.N/L/E/M/B -79/11/01/09/00

PLT COUNT-1.8

RBC -4.8

10/1/25

HB-13.2

TC -11000

N/L/E/M/B -78/12/01/09/00

PLT COUNT-1.5

RBC -4.8

SMEAR NORMOCYTIC NORMOCHROMIC WITH HEMOPARESIS

COMPLETE URINE EXAMINATION (CUE) 05-01-2025 10:14:PMCOLOUR 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 Nil

RFT 05-01-2025 10:14:PMUREA 37 mg/dl 50-17 mg/dlCREATININE 1.0 mg/dl 1.3-0.8 mg/dlURIC

ACID 5.1 mmol/L 7.2-3.5 mmol/LCALCIUM 9.4 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.1 mg/dl 4.5-

2.5 mg/dlSODIUM 140 mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

102 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 05-01-2025 10:14:PMTotal Bilurubin 0.82

mg/dl 1-0 mg/dlDirect Bilurubin 0.20 mg/dl 0.2-0.0 mg/dlSGOT(AST) 13 IU/L 35-0 IU/LSGPT(ALT) 10

IU/L 45-0 IU/LALKALINE PHOSPHATASE 123 IU/L 119-56 IU/LTOTAL PROTEINS 6.2 gm/dl 8.3-6.4

gm/dlALBUMIN 3.88 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.67

Anti HCV Antibodies - RAPID 05-01-2025 11:15:PM Non ReactiveHBsAg-RAPID 05-01-2025

11:15:PM Negative

RFT 06-01-2025 10:54:PMUREA 16 mg/dl 50-17 mg/dlCREATININE 0.9 mg/dl 1.3-0.8 mg/dlURIC

ACID 4.4 mmol/L 7.2-3.5 mmol/LCALCIUM 9.8 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.8 mg/dl 4.5-

2.5 mg/dlSODIUM 139 mmol/L 145-136 mmol/LPOTASSIUM 3.5 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

101 mmol/L 98-107 mmol/LT3, T4, TSH 06-01-2025 10:54:PMT3 0.75 ng/ml 1.87-0.87 ng/mlT4 11.62

micro g/dl 12.23-6.32 micro g/dlTSH 1.15 micro Iu/ml 5.36-0.34 micro Iu/ml

RFT 07-01-2025 11:07:PMUREA 20 mg/dl 50-17 mg/dlCREATININE 1.0 mg/dl 1.3-0.8 mg/dlURIC

ACID 4.6 mmol/L 7.2-3.5 mmol/LCALCIUM 9.6 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.1 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

98 mmol/L 98-107 mmol/LRFT 09-01-2025 12:00:AMUREA 28 mg/dl 50-17 mg/dlCREATININE 1.1

mg/dl 1.3-0.8 mg/dlURIC ACID 4.4 mmol/L 7.2-3.5 mmol/LCALCIUM 9.3 mg/dl 10.2-8.6

mg/dlPHOSPHOROUS 2.6 mg/dl 4.5-2.5 mg/dlSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM

3.5 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 98 mmol/L 98-107 mmol/L

MRI BRAIN PLAIN DONE ON 5/1/25

SMALL ACUTE INFARCT IN SUPERIOR ASPECT OF LEFT CEREBELLAR HEMISPHERE

CHRONIC INFARCT IN SUPERIOR ASPECT OF LEFT CEREBELLAR HEMISPHERE

CHRONIC LACUNAR INFARCT IN LEFT THALAMUS

CARDIOLOGY REFERAL I/V/O ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE WAS

DONE ON 6/1/25

AND ADVICED WITH INJ CARDIANE 150 MG /IV /BOLUS OVER 10 MIN ----. 1 AMP /MIN/6 HRS----

> 0.5 AMP / MIN IN 18 HRS

TAB MET-XL 50 MG /OD 9 AM

INJ LASIX 20 MG IV/BD

COURSE IN HOSPITAL

PATIENT CAME WITH THE COMPLAINTS OF SLURRING OF SPECH SINCE 2 HRS AND ALL

ROUTINE INVESTIGATIONS WERE DONE AND MRI SHOWING ABOVE MENTIONED FINDINGS

WAS DONE AND TREATED WITH ANTIPLATELETS ,ANTICOAGULANTS ,IV ANTIBIOTICS AND

DIURETICS AND PHYSIOTHERAPY WAS DONE PATIENT IS STABLE AND IS BEING

DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION

Treatment Given(Enter only Generic Name)

INJ MONOCEF 1G IV /BD

TAB ASPIRIN 75 MG PO/HS/9PM

TAB ATORVASTATIN 20 MGH PO/HS /9PM

TAB RIVAROXABAN 20 MG PO/OD

TAB MET -XL 50 MG PO/OD/8 AM

TAB DYTOR 10 MG PO/OD/7AM --- 4PM(1/2 TAB)

TAB TELMA 40 MG PO/OD/7 AM

Advice at Discharge

TAB GUDCEF CV 200 MG PO BD X 3 DAY

TAB ASPIRIN 75 MG PO/HS/9PM (TO BE CONTINUED)

TAB ATORVASTATIN 20 MGH PO/HS /9PM (TO BE CONTINUED)

TAB RIVAROXABAN 20 MG PO/OD (TO BE CONTINUED)

TAB MET -XL 50 MG PO/OD/8 AM (TO BE CONTINUED)

TAB DYTOR 10 MG PO/OD/7AM --- 4PM(1/2 TAB) (TO BE CONTINUED)

TAB TELMA 40 MG PO/OD/7 AM (TO BE CONTINUED)

PYSIOTHERAPY OF UPPER AND LOWER LIMBS

Follow Up

REVIEW TO GM OPD AFTER 1 WEEK /SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 41

67years/MALE

D. O. A : 25/11/2024

D. O. D : 29/11/2024

Diagnosis

SEVERE DIMORPHIC ANEMIA, SECONDARY TO HUGE PRE PYLORIC GRASTRIC ULCER (

ACTIVE BLEEDING GASTRIC ULCER) ? DISTAL OESOPHAGIAL FISTULA.(?GI MALIGNANCY )

HEART FAILURE WITH PRESERVED EJECTION TRACTION

CKD

PAROXYSMAL ATRIAL FIBRILLATION

K/C/O HTN AND T2DM SINCE 4 YRS

S/P 2PINT PRBC TRASFUSION

ALCOHOL HARMFUL USE

Case History and Clinical Findings

CHIEF COMPLAINTS

C/O SHORTNESS OF BREATH - 20 DAYS

C/O PAIN ABDOMEN

C/O FACIAL PUFFINES SINCE 20 DAYS

C/O LOW GRADE FEVER SINCE 1 WEEK.

HOPI

PT WAS APPERENTLY ASYMPTOMATIC 20 DYAS BACK THEN HE DEVEOLEPED PAIN

ABDOMEN ,DIFFUSE ,DRAGING TYPE INCREASED AFTER EATRING FOOD. SOB SINCE 20

DAYS GRADE II NYHA PROGRESSIVED TO GRADE III NYHA SINCE 2 DAYS, ORTHOPNEA

PRESENT ,NO PND .

FACIAL PUFFINESS PRESENT,PEDAL EDEMA PRESENT WHICH IS PITTING TYPE GRADE II

,LOW GRADE FEVER SINCE 1 WEEK ON &OFF NO COUGH COLD 

PAST HISTORY;

K/C/O OF DM II SINCE 4 YRS ON TAB.GLICLAZIDE 30 MG PO/OD.

K/C/O HTN SINCE 4YRS ON TAB.ATENOLOL 50 MG + AMLODIPINE 5 MG PO/OD

N/K/C/O ,EPILEPSY,ASTHMA,TB,CVA,CAD,THYROID DISORDER.

GENERAL EXAMINATION :

PATIENT IS C/C/C NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHEDENOPATHY,

EDEMA

BP: 130/70 MMHG

PR: 74 BPM

RR: 22 CPM

SPO2: 94%

SYSTEMIC EXAMINATION :

CVS: S1S2 +

RS: BLAE + NVBS HEARD

P/A:SOFT NT

CNS: NO FND

GASTROLOGY REFERAL DONE I/V/OENDOSCOPY FOR ANY BLEEDING.

ADVICED

T.OLANZAPINE 2.5 MG PO/OD

T.MIRTAZAPINE -7.5 MG/SOS

GASTROENTEROLOGY-DONE -I/V/O MALIGNANCY

ADVICED

UPPER GI ENDOSCOPY DONE :

ESOPHAGUS ;SPASTIC LES,TINY OPENING AT DISTAL ESOPHAGUS

STOMACH ; HUGE ULCERATION AT PRE PYLORIC WITH ACTIVE OOZE

DUODENUM ; CG PERFORMED ,D2 NORMAL

IMPRESSION ;HUGE PREPYLORIC GASTRIC ULCER WITH ACTIVE OOZE .?DISTAL

EOPHAGIAL FISTULA.

COURSE IN HOSPITAL PTB WAS ADMITED WITH ABOVE MENTIONED COMPLAINTS ROUTINE

INVESTIGATION WERE DONE AND FOUND TO Have hb-2.8gm/dl and found to have hepef

secondary to severe anemia surgery referal was done i/v/o ? hemorroids and diagnosed and anal

fissureand advice followedi/v/o severe anemia 2prbc trasfussion were done cect abdomen was done.

gastro referal taken and endoscopy was done.

2 D ECHO REPORT:

MODERATE TO SEVERE TR+PAH,MODERATE MR+,MODERATE AR+

NORWMA

NO AS/MS SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION,NO LV CLOT

EF:68

IVC SIZE 1.8 NON COLLAPSED

MINIMAL PE

CECT REPORT :

B/L SMALL KIDNEY WITH NORMAL ENHANCEMENT

HAIATUS HERNIA

Investigation

BsAg-RAPID 25-11-2024 01:08:PM Negative

Anti HCV Antibodies - RAPID 25-11-2024 01:08:PM Non ReactiveCOMPLETE URINE

EXAMINATION (CUE) 25-11-2024 01:08:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR TraceBILE SALTS NilBILE PIGMENTS NilPUS

CELLS 2-3EPITHELIAL CELLS 2-4RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS

DEPOSITS AbsentOTHERS Nil

RFT 25-11-2024 01:08:PMUREA 53 mg/dl 50-17 mg/dlCREATININE 1.8 mg/dl 1.3-0.8 mg/dlURIC

ACID 8.9 mmol/L 7.2-3.5 mmol/LCALCIUM 9.9 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.1 mg/dl 4.5-

2.5 mg/dlSODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 4.6 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

102 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 25-11-2024 01:08:PMTotal Bilurubin 0.53

mg/dl 1-0 mg/dlDirect Bilurubin 0.15 mg/dl 0.2-0.0 mg/dlSGOT(AST) 16 IU/L 35-0 IU/LSGPT(ALT) 20

IU/L 45-0 IU/LALKALINE PHOSPHATASE 166 IU/L 119-56 IU/LTOTAL PROTEINS 5.2 gm/dl 8.3-6.4

gm/dlALBUMIN 3.24 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.65

RFT 25-11-2024 10:48:PMUREA 53 mg/dl 50-17 mg/dlCREATININE 1.6 mg/dl 1.3-0.8 mg/dlURIC

ACID 9.6 mmol/L 7.2-3.5 mmol/LCALCIUM 9.5 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.62 mg/dl 4.5-

2.5 mg/dlSODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 3.6 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

101 mmol/L 98-107 mmol/L

HEMOGRAM ;

25/11/2024

HB;2.8

TLC;7200

N/L/E/M ;73/18/00/09

PCV;10.6

MCV;65.4

MCH;17.3

MCHC;26.4

RBC ;1.62

PTL;1.9

28/11/24

HB;8.3

TLC;8800

N/L/E/M/B ;68/22/03/07/00

PCV;25.2

MCV;71.8

MCH;23.6

MCHC;32.9

RBC ;3.51

PTL;2.39

SERUM OSMOLARITY 292 mOSML/KG

RFT 28/11/24

UREA 40 MG/DL

CREATININE 1.6

URIC ACID 10.4

CALCIUM 9.8

PHOSPHORUS 3.3

SODIUM 134

POTASIUM 3.6

CHLORIDE 98

Treatment Given(Enter only Generic Name)

1.FLUID RESTRICTION <1.5ML/DAY

2.SALT RESTRICTION<2G/DAY

3.INJ. THIAMINE 200MG IN 100ML NS IV/BD

4.INJ.LASIZ 20MG IV/BD

5. INJ. VITCOFOL 2 CC IM/OD

6.TAB METRONIDAZOLE 400MG PO/TID

7.TAB GLICLAZIDE 30MG PO/OD

8.TAB CINOD 10MG PO/OD

9.TAB.N-ACETYLCYSTINE 600MG PO/BD

10.OINT.SMUTH FOR LA/BD

11.SYP.CREMAFFIN 15 ML PO/HS

12.SITZ BATH WITH BETADINE TID

Advice at Discharge

REFER TO HIGHER CENTERPATIENT AND PATIENT ATTENDER HAVE BEEN EXPALINED

ABOUT PATIENTS CONDITION i.e HFPEF SECONDARY TO SEVERE DIMORPHIC ANEMIA B12

DEFICIENCY - BLOOD LOSS SECONDARY TO HUGE PRE PYLORIC GRASTRIC ULCER (

ACTIVE OOZE) ? DISTAL OESOPHAGIAL FISTULA.CKD,PAROXYSMAL ATRIAL

FIBRILLATION,K/C/O HTN AND T2DM SINCE 4 YRS,S/P 2PINT PRBC TRASFUSION,ALCOHOL

HARMFUL USE.EXPLAINED IN THEIR OWN LAUNGUAGE THAT IS TELUGU.WE EVEN

EXPLAINED ABOUT THE COMPLICATION ,.RISK ASSOCIATEDWITH THE PATINET CONDITION

AND PATIENT IS BEINGREFFERED TO HIGHER CENTER I/V/VO FURTHER MANAGEMENT i.e

INTERVENTION FROM MEDICAL - SURGICAL GATROENTEROLOGIST.DOCTORS,HOSPITAL

STAFF AND MANAGEMENT ARE NOT RESPONSIBLE FOR PATIENT CONDITION &OUTCOME

OF PATIENT.

Follow Up

REVIEW SOS TO GM OPD

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 42

84years/MALE

D. O. A : 21/11/2024

D. O. D : 29/11/2024

Diagnosis

COMMUNITY ACQUIRED PNEUMONIA (RESOLVED)

TYPE II RESPIRATORY FAILURE (RESOLVED)

PAROXYSMAL ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE

HFmEF (EF =45%)

K/C/O BRONCHIAL ASTHMA

Case History and Clinical Findings

CHIEF COMPLAINTS

C/O SOB SINCE MORNING

FEVER SINCE 5 DAYS

COUGH SINCE 5 DAYS

HISTORY OF PRESENT ILLNESS

PATIENT WAS APPARENTLY ASYMPTOMATIC 5 DAYS BACK AFTER WHICH HE DEVELOPED

FEVER ASSOCIATED WITH CHILLS AND RIGOR INTERMITTENT IN NATURE . COMPLAINTS OF

COUGH WITH SPUTUM SINCE 5 DAYS WHITE IN COLOUR , CUPIOUS IN AMOUNT C/O

SHORTNES OF BREATH SINCE 5 DAYS PROGRESSED FROM GRADE1 TO GRADE 3

AGGRAVATED ON DOING WORK

NO C/O CHEST PAIN ,ORTHOPNEA,ABDOMINAL PAIN,VOMITING , NAUSEA ,DIARRHEA ,

BURNING MICTURITION , PEDAL EDEMA

PAST ILLNESS

N/K/C/O DM,TB,ASTHMA,CVA,CAD ,EPILEPSY

PERSONAL HISTORY:

OCCUPATION- FARMER

APPETITE - NORMAL

BOWEL AND BLADDER -REGULAR

ADDICTIONS- ALCOHOLIC OCCASIONAL 90ML

GENERAL EXAMINATION:

NO PALLOR ICTERUS CYANOSIS CLUBBING LYMPHADENOPATHY OEDEMA

BP: 110/70 MMHG

PR:150 BPM

RR: 30 CPM

TEMPERATURE: AFBRILE

SPO2: 100% AT RA

CVS: NO THRILLS, S1S2 +, NO MURMURS

RS: BAE+,NVBS

PER ABDOMEN:

SOFT , NON TENDER

CNS : NF ND

PUMONOLGY REFFERAL WAS DONE ON 22/11/24 I/V/O K/C/O BRONCHIAL ASTHMA

ADVICE ;-

CONTINUE SAME TREATMENT

STABILIZE CARDIAC CONDITION

NO INTERVENETION NEEDED FROM PULMONOLGY

REVIEW REFFERAL OF PULMONOLGY DONE ON 25/11/24

ADVICE:-

CONTINUE SAME TREATMENT

INJ.HYDROCORT 100MG IV/TID

SYRUP.ASCORIL-LS PO/TID 2 TSBP

Investigation

NameValueRangeNameValueRangeABG 21-11-2024 10:43:PM

PH7.24PCO278.4PO251.1HCO332.8St.HCO327.4BEB3.8BEecf5.9TCO269.6O2 Sat78.3O2

Count12.7RFT 21-11-2024 11:25:PM UREA64 mg/dl50-17 mg/dlCREATININE1.1 mg/dl1.3-0.8

mg/dlURIC ACID3.7 mmol/L7.2-3.5 mmol/LCALCIUM8.8 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.7

mg/dl4.5-2.5 mg/dlSODIUM140 mmol/L145-136 mmol/LPOTASSIUM3.8 mmol/L.5.1-3.5

mmol/L.CHLORIDE106 mmol/L98-107 mmol/LLIVER FUNCTION TEST (LFT) 21-11-2024 11:25:PM

Total Bilurubin1.16 mg/dl1-0 mg/dlDirect Bilurubin0.25 mg/dl0.2-0.0 mg/dlSGOT(AST)97 IU/L35-0

IU/LSGPT(ALT)355 IU/L45-0 IU/LALKALINE PHOSPHATASE147 IU/L119-56 IU/LTOTAL

PROTEINS5.5 gm/dl8.3-6.4 gm/dlALBUMIN3.11 gm/dl4.6-3.2 gm/dlA/G RATIO1.30COMPLETE

URINE EXAMINATION (CUE) 21-11-2024 11:25:PM COLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN+SUGARNilBILE

SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS2-3RED BLOOD

CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilRFT 22-11-2024

12:13:AM UREA69 mg/dl50-17 mg/dlCREATININE1.1 mg/dl1.3-0.8 mg/dlURIC ACID3.9 mmol/L7.2-

3.5 mmol/LCALCIUM9.3 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.8 mg/dl4.5-2.5 mg/dlSODIUM137

mmol/L145-136 mmol/LPOTASSIUM4.2 mmol/L.5.1-3.5 mmol/L.CHLORIDE101 mmol/L98-107

mmol/LABG 22-11-2024 12:13:AM

PH7.24PCO275.9PO237.3HCO331.9St.HCO326.4BEB3.1BEecf5.0TCO268.0O2 Sat57.8O2

Count9.3ABG 22-11-2024 12:46:AM

PH7.23PCO280.0PO299.2HCO332.7St.HCO327.6BEB3.6BEecf5.7TCO269.5O2 Sat96.4O2

Count15.5ABG 22-11-2024 01:06:PM

PH7.294PH7.29PH7.29PCO265.8PCO265.8PCO265.8PO236.0PO236.0PO236.0HCO331.0HCO33

1.0HCO331.0St.HCO326.6St.HCO326.6St.HCO326.6BEB3.4BEB3.4BEB3.4BEecf4.9BEecf4.9BEecf

4.9TCO265.2TCO265.2TCO265.2O2 Sat58.4O2 Sat58.4O2 Sat58.4O2 Count9.5O2 Count9.5ABG

22-11-2024 06:58:PM PH7.267PCO258.6PO2202HCO325.8St.HCO323.7BEB-0.9BEecf-

0.3TCO256.6O2 Sat99.1O2 Count11.6RFT 22-11-2024 10:29:PM UREA64 mg/dl50-17

mg/dlCREATININE1.2 mg/dl1.3-0.8 mg/dlURIC ACID4.4 mmol/L7.2-3.5 mmol/LCALCIUM8.6

mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.1 mg/dl4.5-2.5 mg/dlSODIUM139 m

mol/L145-136 mmol/LPOTASSIUM3.7 mmol/L.5.1-3.5 mmol/L.CHLORIDE99 mmol/L98-107

mmol/LABG 22-11-2024 10:29:PM

PH7.33PCO267.4PO2100HCO335.0St.HCO331.6BEB7.9BEecf9.1TCO273.6O2 Sat97.4O2

Count13.9ABG 23-11-2024 02:45:PM

PH7.36PCO262.0PO294.4HCO334.3St.HCO332.0BEB8.2BEecf8.8TCO274.0O2 Sat97.5O2

Count10.6RFT 23-11-2024 11:27:PM UREA44 mg/dl50-17 mg/dlCREATININE1.1 mg/dl1.3-0.8

mg/dlURIC ACID3.3 mmol/L7.2-3.5 mmol/LCALCIUM8.7 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.0

mg/dl4.5-2.5 mg/dlSODIUM136 mmol/L145-136 mmol/LPOTASSIUM3.5 mmol/L.5.1-3.5

mmol/L.CHLORIDE98 mmol/L98-107 mmol/LABG 23-11-2024 11:27:PM

PH7.41PCO262.5PO249.1HCO339.6St.HCO336.0BEB12.5BEecf14.3TCO278.8O2 Sat83.5O2

Count15.4ABG 24-11-2024 06:17:PM

PH7.43PCO255.7PO248.5HCO337.0St.HCO334.2BEB10.8BEecf12.1TCO272.8O2 Sat82.9O2

Count15.9RFT 24-11-2024 10:43:PM UREA42 mg/dl50-17 mg/dlCREATININE1.0 mg/dl1.3-0.8

mg/dlURIC ACID2.7 mmol/L7.2-3.5 mmol/LCALCIUM9.0 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.2

mg/dl4.5-2.5 mg/dlSODIUM136 mmol/L145-136 mmol/LPOTASSIUM3.4 mmol/L.5.1-3.5

mmol/L.CHLORIDE97 mmol/L98-107 mmol/LABG 24-11-2024 10:43:PM

PH7.37PCO268.2PO236.4HCO338.8St.HCO333.5BEB10.8BEecf13.1TCO277.4O2 Sat62.4O2

Count12.7RFT 25-11-2024 11:25:PM UREA51 mg/dl50-17 mg/dlCREATININE1.2 mg/dl1.3-0.8

mg/dlURIC ACID2.5 mmol/L7.2-3.5 mmol/LCALCIUM9.5 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.0

mg/dl4.5-2.5 mg/dlSODIUM136 mmol/L145-136 mmol/LPOTASSIUM3.5 mmol/L.5.1-3.5

mmol/L.CHLORIDE97 mmol/L98-107 mmol/LABG 25-11-2024 11:25:PM

PH7.42PCO260.6PO230.9HCO339.2St.HCO335.5BEB12.8BEecf14.1TCO280.4O2 Sat50.6O2

Count8.3

CBP ON 27/11/24

HAEMOGLOBIN 11.3 gm/dl TOTAL COUNT 11,700 cells/cumm NEUTROPHILS 87 %

LYMPHOCYTES 06 % EOSINOPHILS 01 %MONOCYTES 06 % BASOPHILS 00 % PLATELET

COUNT 2.74 lakhs/cu.mm

ABG ON 27/11/24

PH 7.45 PCO2 46.7 mmHgPO2 57.8 mmHg HCO3 32.7 mmol/LSt.HCO3 31.8 mmol/LBEB 8.2

mmol/LBEecf 8.5 mmol/LTCO2 67.0 VOLO2 Sat 89.8 %O2 Count 13.0 vol %

RFT ON 27/11/24

UREA 54 mg/dl 17 - 50 CREATININE 1.2 mg/dlURIC ACID 2.8 mmol/LCALCIUM 10.1 mg/dl

PHOSPHOROUS 2.0 mg/dl SODIUM 136 mmol/L POTASSIUM 3.7 mmol/L. CHLORIDE 98 mmol/L

2D-ECHO DONE ON 22/11/24

TACHCARDIA DURING STADY

RWMA LAD TERRITORY HYPOKINESIA

MILD MR(MR JET AREA 3.8CM )

 MILD AR (AR-PHT 518ML/SEC)

MILD TR WITH PAH (RVSP2 35 +05240 MM/HG)

EF=45%MILD TO MODERATE LV DYSFUNCTION

GRADE -I DIASTOLIC DYSFINCTION

MINIMAL PE , NO LV CLOT

IVC SIZE 1.45 CM , NON COLLAPSING

SCLEROTIC AV , NO AS/MS ,IAS -INTACT /ANEURYSM

Treatment Given(Enter only Generic Name)

INJ.AUGMENTIN 1,2 GM IV/BD

INJ.LASIX 20MG IV/BD

NEB. WITH IPRAVENT AT 6TH HOURLY

 BUDECORD AT 8TH HOURLY

 MUCOMIST AT 8TH HOURLY

TAB.AZITHROMYCIN 500MG PO/OD

TAB.MET -XL 25MG PO/ODTAB.ELIQUS 2.5MG PO/OD TAB.DIGOXIN 0.25 PO/OD

Advice at Discharge

TAB METXL 25MG PO/BD

1-0-0 TO CONTINUE

TAB ELIQUS 2.5MG PO/OD

1-0-0 TO CONTINUE

TAB DIGOXIN 0.25MG PO/OD

1-0-0 TO CONTINUE

MDI FORACORT 200MCG 2PUFFS

1-----1----1 X 5 DAYS FB 2 PUFFS SOS

OINT THROMBOPHOBE L/A TID X 3 DAYS

SYP ASCORIL IS PO/TID

15ML-15ML-15ML X 3 DAYS

HOME OXYGENATION INTERMITTENTLY

Follow Up

REVIEW TO GM OPD AFTER 15 DAYS /SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 43

62years/MALE

D. O. A : 20/11/2024

D. O. D : 22/11/2024

Diagnosis

ACUTE ON CHRONIC LVF

HEART FAILURE WITH REDUCED EF 30% WITH PERMANENT ATRIAL FIBRILLATION WITH

FVR

CHRONIC HEALING ULCER OVER LEFT THIGH 3 MONTHS

K/C/O HYPERTENSION 15 YRS

Case History and Clinical Findings

C/O COUGH SINCE 1 DAY

HOPIPATIENT WAS APPARENTLY ASSYMPTOMATIC 1 DAY AGO THRN HE DEVELOPED COUGH ,

INSIDIOUS ONSET A/W SPUTUM MUCOID SPUTUM , NON BLOOD TINGED MORE AT NIGHT

AND LESS DURING MORNING .

H/O BREATHLESS

H/O PEDAL OEDEMA ON AND OFF

NO H/O FEVER AND COLD

NO H/O DECREASED URINE OUTPUT AND BURNING MICTURATION

NO H/O VOMITING , LOOSE STOOLS AND PAIN ABDOMEN

PAST HISTORY - H/O CELLULITIS 3 MONTHS BACK

K/C/O HYPERTENSION 15 YEARS

K/C/O ATRIAL FIBRILLATION 10 YEARS

K/C/O HEART FAILURE WITH HFrEF

K/C/O RECURRENT PEUMONIA

NOT K/C/O CVA, EPILEPSY , THYROID DISORDERS, TB, ASTHMA.

PERSONAL HISTORY -

DIET MIXED

APPETITE - NORMAL

BOWEL AND BLADDER MOVEMENTS ARE REGULAR

SLEEP ADEQUATE

FAMILY HISTORY - NOT SIGNIFICANT

GENERAL EXAMINATION -

NO PALLOR

PEDAL OEDEMA IS PRESENT

NO ICTERUS

NO CYANOSIS

NO CLUBBING

NO KOILONYCHIA

TEMPERATURE - 98 F

PR - 100 BPM

RR- 32 CPM

BP- 100/60 MMHG

SPO2 - 95% AT RA

SYSTEMIC EXAMINATION -

CVS -

S1S2 HEARD

NO MURMURS ,

NO THRILLS

RESPIRATORY SYSTEM -

DYSPNOEA - PRESENT

NO WHEEZE

TRACHEA CENTRAL

NVBS + , BAE+

PER ABDOMEN -

OBESE SHAPE

SOFT AND NON TENDER

BOWEL SOUNDS HEARD IN RIF

CNS - NO FND

GS REFERRAL DONE ON 20/11/24 I/V/O RAW AREA OVER LEFT MEDIAL ASPECT OF THIGH

AND KNEE

ADVISED:

DIAGNOSIS: HEALING ULCER OVER THE LEFT THIGH SECONDARY TO CELLULITIS

LEFT LOWER LIMB ELEVATION

MEGAHEAL OINTMENT FOR L/A

REGULAR DRESSINGS

PLASTIC SURGERY OPINION I/V/O SSG

INVESTIGATIONS ADVISED; X RAY LEFT THIGH AP LATERAL

RFT, CRP, WOUND CULTURE C/S

WOUND CULTURE C/S REPORT AWAITED.

COURSE IN HOSPITALA 62 YR OLD MALE WAS BROUGHT TO CASUAlITY WITH COMPLAINTS OF COUGH WITH

SPUTUM SINCE PREVIOUS DAY NIGHT ,A/W BREATHLESSNESS SINCE THEN,PATIENT IS A

KNOWN CASE OF HFrEF WITH ATRIAL FIBRILLATION .ON FURTHER EVALUATION PATIENT

FOUND TO HAVE ACUTE ON CHRONIC VENTRICULAR FAILURE . TREATMENT WAS STARTED

ACCORDINGLY.LATER PATIENT WAS FOUND TO HAVE CHRONIC HELAING ULCER OVER

LEFT THIGH FOR WHICH SURGERY OPINION WAS TAKEN AND TREATED ACCORDINGLY.

PATIENT IMPROVED CLINICALLY HE IS BEING DISCHARGED IN A HAEMODYNAMICALLY

STABLE CONDITION

Investigation

COMPLETE URINE EXAMINATION (CUE) 20-11-2024COLOUR 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

Anti HCV Antibodies - RAPID 20-11-2024 Non ReactiveHBsAg-RAPID 20-11-2024 Negative

HIV 1/2 Rapid Test Non Reactive

 RFT 20-11-2024UREA 23 mg/dl CREATININE 1.1 mg/dl URIC ACID 3.0 mmol/L CALCIUM 9.8

mg/dlPHOSPHOROUS 2.4 mg/dl SODIUM 142 mmol/L POTASSIUM 3.7 mmol/L.CHLORIDE 106

mmol/L

LIVER FUNCTION TEST (LFT) 20-11-2024Total Bilurubin 1.56 mg/dl Direct Bilurubin 0.45

mg/dlSGOT(AST) 14 IU/LSGPT(ALT) 10 IU/L ALKALINE PHOSPHATASE 207 IU/LTOTAL

PROTEINS 5.6 gm/dlALBUMIN 2.97 gm/dlA/G RATIO 1.13

APTT TEST 31

Prothrombin Time 15 secINR 1.11

HAEMOGLOBIN 10.5 gm/dlTOTAL COUNT 7,200 cells/cummNEUTROPHILS 80LYMPHOCYTES

9EOSINOPHILS 1MONOCYTES 10BASOPHILS 00PCV 32.5 vol %PLT- 2.65USG ON 20/11/202427

X 26 MM CYST NOTED IN THE MIDPOLE OF RIGHT KIDNEYFREE FLUID NOTED IN BILATERAL

PLEURAL SPACEIMPRESSION -RIGHT SIMPLE RENAL CORTICAL CYSTB/L PLEURAL

EFFUSION2D ECHO;TACHYCARDIA AND VPCS DURING STUDY

EF- 30%, IVC SIZE- 2.3CMS DILATED COLLAPSING

SEVERE TR PAH, MOD TO SEVERE MR, MODERATE MR, MILD PR

RWMA [+] LAD AKINETIC ; LCX AND RCA HYPOKINESIA NO AS/MS

SEVERE LV DYSFUNCTION

NO DIASTOLIC DYSFUNCTION NO PE/LV CLOT

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION LESS THAN 1.2 L / DAY

SALT RESTRICTION LESS THAN 1.2 G/DAY

INJ. LASIX 40 MG IV STAT

INJ. LASIX 40 MG IV TID

TAB. MET XL 25 MG PO/OD

INJ . AUGMENTIN 1.2 GRM IV TID X 3DAYS

INJ. DOXYCYCLIN 100 MG IV BD X 3DAYS

TAB DYTOR PLUS 3/25 PO/OD 8AM-X-X

TAB DYTOR 5 MG PO/OD X-X-4PM

TAB. DABIGATRAN 110 MG PO/BD 1-X-1

TAB ECOSPIRIN AV 75/20PO HS X-X-1

TAB SALUBITRIL + VALSARTAN ( 26+ 24) PO 1/2 BD

Advice at Discharge

FLUID RESTRICTION LESS THAN 1.2 L / DAY

SALT RESTRICTION LESS THAN 1.2 G/DAY

TAB DYTOR PLUS 3/25 PO/OD 8AM-X-X TO BE CONTINUE

TAB DYTOR 5 MG PO/OD X-X-4PM TO BE CONTINUE

TAB. DABIGATRAN 110 MG PO/BD 1-X-1 TO BE CONTINUE

TAB ECOSPIRIN AV 75/20 PO HS X-X-1 TO BE CONTINUE

TAB. MET XL 25 MG PO/BD 1-X 1/2 TO BE CONTINUE

TAB SALUBITRIL + VALSARTAN ( 26+ 24) PO BD 1/2 -X-1/2 TO BE CONTINUE

LEFT LOWER LIMB ELEVATION

MEGAHEAL OINTMENT FOR L/A

REGULAR DRESSINGS

Follow Up

REVIEW ON 27/11/24 OR SOS TO GM OPD

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 44

58years/MALE

D. O. A : 12/11/2024

D. O. D : 17/11/2024

Diagnosis

ATRIAL FLUTTER WITH VARIABLE BLOCK(RESOLVED)---->ATRIAL FIBRILLATION WITH FVR

HEART FAILURE WITH REDUCED EJECTION FRACTION (EF: 38%)

PRERENAL AKI ON CKD CARDIORENAL SYNDROME II(RESOLVING)

K/C/O VALVULAR ATRIAL FIBRILLATION WITH FVR SECONDARY TO

CHRONIC RHEUMATIC HEART DISEASE WITH MODERATE MS SINCE 5 YEARS

COPD, DENOVO T2DM

Case History and Clinical Findings

CHIEF COMPLAINTS:

C/O FEVER 10 DAYS BACK, COUGH, BREATHLESSNESS SINCE 10 DAYS

HOPI:

PT WAS APPARANTLY AYMPTOMATIC 10 DAYS BACK, THEN DEVELOPED FEVER, HIGH

GRADE WITH CHILLS, LASTED FOR 1 DAY, DRY COUGH, BREATHLESSNESS GRADE 3 MMRC

H/O DECREASED URINE OUTPUT FOR 1 DAY

H/O PEDAL EDEMA ON AND OFF, PALPITATIONS ON AND OFF

NO H/O CHEST PAIN, ORTHOPNEA, PND

NO H/O PAIN ABDOMEN, VOMITINGS, LOOSE STOOLS

H/O PLEURAL TAP 10 YEARS BACK.

PAST HISTORY:

K/C/O CRHD SINCE 5 YEARS WITH AF WITH FVR

K/C/O HTN SINCE 3 YEARS AND IS ON MEDICATION

ISOSORBIDE DINITRATE 20 MG TWICE, SINCE 3 MONTHS

DILTIAZEM 90 MG SINCE 5 DAYS, STOPPED METXL 50 MG SINCE 5 DAYS

LASIX 40 MG IN AFTERNOON SINCE 5 DAYS

EPLERENONE 25 MG SINCE 5 DAYS ( USED FOR 1 WEEK 2 MONTHS BACK)

APIXABAN 5 MG SINCE 3 MONTHS

ROSUVAS 10 MG SINCE 3 MONTHS

N/K/C/O DM,THYROID DISORDERS ,EPILESY,TB.

PERSONAL HISTORY

APPETITE NORMAL

SLEEP ADEQUATE

BOWEL MOVEMENTS REGULAR

BLADDER MOVEMENTS REGULAR

ADDICTIONS : ALCOHOL STOPPED 5 YRS AGO

BEEDI STOPPED 5 YRS AGO .

FAMILY HISTORY NOT SIGNIFICANT

GENERAL EXAMINATION

PT IS CONSCIOUS COHERENT COOPERATIVE

NO PALLOR ICTERUS CYANOSIS CLUBBINGLYMPHADENOPATHY PEDAL EDEMA

VITALS:

TEMPERATURE AFEBRILE

BP 100/70 MMHG

PR 85 BPM

RR 18 CPM

SPO2 98%AT RA

SYSTEMIC EXAMINATION

CVS - S1S2 HEARD

PA - SOFT NON TENDER

CNS - NO FOCAL NEUROLOGICAL DEFICIT

RS - BAE+ CREPTS + IN IAA, ISA

COURSE IN HOSPITAL:-58 YEAR OLD MALE K/C/O CRHD WITH AF WITH FVR SINCE 5YEARS AND HYPERTENSION

SINCE 3YEARS WAS BRUGHT TO CASUALTY WITH C/OFEVER, COUGH AND

BREATHLESSNESS SINCE 10DAYS. VITALS AT ADMISSION BP-100/70MMHG, PR-52BPM,HR IN

MONITOR-162,RR-18CPM, SPO2-96%@RA. ON AUSCULTATION CREPTS + DIFFUSELY IN ALL

AREAS, TAB.METXL 25MG WAS GIVEN AND STARTED ON CPAP SUPPORT.ON FURTHER

INVESTIGATION DIAGNOSED AS ATRIAL FLUTTER WITH VARIABLE BLOCK, HEART FAILURE

WITH REDUCED EJECTION FRACTION (EF: 38%) PRERENAL AKI ON CKD- CARDIORENAL

SYNDROME II, VALVULAR ATRIAL FIBRILLATION WITH FVR SECONDARY TO CHRONIC

RHEUMATIC HEART DISEASE WITH MODERATE MS, COPD, DENOVO T2DM TREATED WITH

CPAP SUPPORT, IV FLUIDS,DIURETICS, ANTIBIOTICS,MET-XL 50MG BD,CARDARONE 200MG

TID AND NEBULIZATION AND OHAs. AT ADMISSION STARTED ON ANTICOAGULANTS BUT

HEMATURIA WAS STARTED AND HENCE ANTICOAGULANT WAS STOPPED.HEART RATE

WAS CONTROLLED AND BREATHLESSNESS SUBSIDED, NO FEVER SPIKES WERE PRESENT

AND AKI WAS RESOLVED. PATIENT WAS IMPROVED CLINICALLY AND DISCHARGED IN

HAEMODYNAMICALLY STABLE CONDITION.

Investigation

HBsAg-RAPID 12-11-2024 07:18:PM Negative

Anti HCV Antibodies - RAPID 12-11-2024 07:18:PM NEGATIVE KIT NAME : ALER TRUE LINE

HBsAg-RAPID Negative

HIV 1/2 Rapid Test Non Reactive

FBS 164 mg/dl

HbA1c 7.3 %

HAEMOGRAM 12/11/24:

HAEMOGLOBIN 13.3 gm/dl TOTAL COUNT 18,000 cells/cumm NEUTROPHILS 85 %

LYMPHOCYTES 08 % EOSINOPHILS 01 % MONOCYTES 06 % BASOPHILS 00 % PCV 37.8 vol %

M C V 84.6 fl M C H 29.6 pg M C H C 35.2 %RDW-CV 14.8 % RDW-SD 45.8 fl RBC COUNT 4.47

millions/cumm PLATELET COUNT 1.40 lakhs/cu.mm SMEARRBC Normocytic normochromic WBC

With in normal limits PLATELETS Adeqaute HEMOPARASITES No hemoparasites seen

IMPRESSION Normocytic normochromic blood picture with neutrophilic leukocytosis

LFT 13/11/24:

Total Bilurubin 1.66 mg/dl Direct Bilurubin 0.55 mg/dl SGOT(AST) 23 IU/L SGPT(ALT) 14 IU/L

ALKALINE PHOSPHATASE 227 IU/L TOTAL PROTEINS 6.1 gm/dl ALBUMIN 3.2 gm/dl A/G RATIO

1.13

COMPLETE URINE EXAMINATION (CUE) 12-11-2024 07:18: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

BLOOD UREA 12-11-2024 07:18:PM 165 mg/dl SERUM CREATININE 12-11-2024 07:18:PM 3.6

mg/dl

SERUM ELECTROLYTES (Na, K, C l) 12-11-2024 07:18:PMSODIUM 131 mmol/L POTASSIUM 3.8

mmol/L CHLORIDE 99 mmol/L

ABG 12-11-2024 08:08:PMPH 7.41PCO2 28.1PO2 88.0HCO3 17.5St.HCO3 20.1BEB -5.2BEecf -

6.2TCO2 34.0O2 Sat 96.4O2 Count 20.0

TROPONIN-I 37.8 pg/ml

BLOOD UREA 13-11-2024 06:04:AM 180 mg/dl

SERUM CREATININE 13-11-2024 06:04:AM 3.6 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 13-11-2024 06:04:AMSODIUM 130 mmol/L POTASSIUM 3.6

mmol/LCHLORIDE 99 mmol/L

HAEMOGRAM 13/11/24:

HAEMOGLOBIN 13.5 gm/dl TOTAL COUNT 15,500 cells/cummNEUTROPHILS 85

%LYMPHOCYTES 08 % EOSINOPHILS 02 % MONOCYTES 05 % BASOPHILS 00 % PCV 38.7 vol

% M C V 85.4 fl M C H 29.8 pgM C H C 34.9 % RDW-CV 15.1 %RDW-SD 47.1 flRBC COUNT 4.53

millions/cumm PLATELET COUNT 1.35 lakhs/cu.mm SMEARRBC Normocytic normochromic WBC

neutrophilic leukocytosis PLATELETS mild thrombocytophenia HEMOPARASITES No hemoparasites

seenIMPRESSION Normocytic normochromic blood picture with neutrophilic leukocytosis and mild

thrombocytophenia

APTT TEST 31 Sec

Prothrombin Time 16 Sec INR 1.11

COMPLETE URINE EXAMINATION (CUE) 13-11-2024 07:49:AMCOLOUR 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 NilBLOOD UREA 14-11-

2024 10:08:PM 174 mg/dl

SERUM CREATININE 14-11-2024 10:08:PM 3.3 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 14-11-2024 10:08:PMSODIUM 133 mmol/L POTASSIUM 3.5

mmol/L CHLORIDE 99 mmol/L

HAEMOGRAM 14/11/24:

HAEMOGLOBIN 12.6 gm/dlTOTAL COUNT 15,900 cells/cumm NEUTROPHILS 85 %

LYMPHOCYTES 08 % EOSINOPHILS 02 %MONOCYTES 05 % BASOPHILS 00 % PCV 36.2 vol %

M C V 85.6 fl M C H 29.8 pg M C H C 34.8 %RDW-CV 15.1 %RDW-SD 47.0 fl RBC COUNT 4.23

millions/cumm PLATELET COUNT 1.5 lakhs/cu.mm SMEARRBC Normocytic normochromic WBC

neutrophilic leukocytosis PLATELETS Adeqaute HEMOPARASITES No hemoparasites seen

IMPRESSION Normocytic normochromic blood picture with neutrophilic leukocytosis

Blood Urea 150 mg/dl 15/11/24

Serum Creatinine 3.0 mg/dl 15/11/24

SERUM ELECTROLYTES (Na, K, C l) 15-11-2024

SODIUM 136 mmol/LPOTASSIUM 3.5 mmol/L CHLORIDE 98 mmol/L CALCIUM IONIZED 0.99

mmol/L

HAEMOGRAM 15/11/24:

HAEMOGLOBIN 12.8 gm/dl TOTAL COUNT 15,500 cells/cumm NEUTROPHILS 85 %

LYMPHOCYTES 09 % EOSINOPHILS 01 %MONOCYTES 05 % BASOPHILS 00 %PCV 37.5 vol %

M C V 86.2 flM C H 29.4 pg M C H C 34.1 % RDW-CV 14.7 % RDW-SD 46.8 flRBC COUNT 4.35

millions/cumm PLATELET COUNT 1.56 lakhs/cu.mm SMEARRBC Normocytic normochromic WBC

neutrophilic leukocytosis PLATELETS Adeqaute HEMOPARASITES No hemoparasites seen

IMPRESSION Normocytic normochromic blood picture with neutrophilic leukocytosis

LFT 15/11/24:

Total Bilurubin 1.14 mg/dl Direct Bilurubin 0.20 mg/dl SGOT(AST) 10 IU/LSGPT(ALT) 14 IU/L

ALKALINE PHOSPHATASE 128 IU/L TOTAL PROTEINS 5.2 gm/dlALBUMIN 2.6 gm/dl A/G RATIO

1.01

HbA1c 7.1 % 15/11/24

Blood Urea 139 mg/dl 16/11/24

Serum Creatinine 2.8 mg/dl 16/11/24

SERUM ELECTROLYTES (Na, K, C l) 16-11-2024

SODIUM 138 mmol/L POTASSIUM 3.3 mmol/L CHLORIDE 102 mmol/L CALCIUM IONIZED 1.03

mmol/L

HAEMOGRAM 16/11/24:

HAEMOGLOBIN 14.3 gm/dl TOTAL COUNT 18,400 cells/cumm NEUTROPHILS 85 %

LYMPHOCYTES 09 % EOSINOPHILS 01 % MONOCYTES 05 %BASOPHILS 00 % PCV 41.5 vol

%M C V 86.8 flM C H 29.9 pgM C H C 34.5 % RDW-CV 14.8 % RDW-SD 46.6 flRBC COUNT 4.78

millions/cumm PLATELET COUNT 1.91 lakhs/cu.mmSMEARRBC Normocytic normochromic WBC

With in normal limits PLATELETS Adeqaute HEMOPARASITES No hemoparasites

seenIMPRESSION Normocytic normochromic blood picture with neutrophilic leukocytosis

2D ECHO BEDSIDE:

TACHYCARDIA DURING STUDY

SINUS ARRYTHMIA

ALL CHAMBERS DILATED

RWMA LAD TERRITORY HYPOKINETIC, RCA AND LCX HYPOKINESIA (MILD LVH)

MILD TO MODERATE MR(MR JET AREA 5.0CM2)

MILD AR

MODERATE TO SEVERE TR WITH MODE PAH

IVC SIZE(2.08CM2) DILATED NON COLLAPSING

CALCIFIED AV, THICKENED, MILD AS

MODERATE MS

EF-38%, MODERATE LV DYSFUNCTIONAL

NO PE/LV CLOT

USG ABDOMEN:

INCREASED ECHOGENICITY OF RIGHT KIDNEY

LEFT KIDNEY GRADE-I RPD CHANGES

Treatment Given(Enter only Generic Name)

IV FLUIDS NS @50ML/HR

CONTINOUS CPAP SUPPORT

INJ. PIPTAZ 2.25 GM IV/TID FOR 3DAYS

INJ PAN 40 MG IV/OD

INJ LASIX 40 MG IV/TID

T. DOXYCYLINE 100MG PO/BD FOR 7DAYS

T.AUGMENTIN 625MG PO/TID FOR 7DAYS

T. CARDARONE 200 MG PO/TID

T. METXL 50 MG PO/BD

T. DIGOXIN 0.5 MG PO STAT FOLLOWED BY 0.25MG ON ALTERNATE DAY

T.SITAGLIPTIN 5OMG PO/OD

NEBULISATION WITH IPRAVENT 4 TH HRLY ANF BUDECORT 6 TH HRLY

Advice at Discharge

T.DYTOR PLUS 10/50 PO/BD AT 8AM

T.DYTOR PLUS 10MG PO/OD AT 4PM

T. CARDARONE 200 MG PO/TID CONTINUE

T. METXL 50 MG PO/BD CONTINUE

T. DIGOXIN 0.25 MG PO/OD AT 8AM ON ALTERNATE DAYS

T.SITAGLIPTIN 50MG PO/OD BEFORE BREAKFAST

T.MONTEK-AB PO/BD X 1WEEK

T.NEPHROSAVE PO/BD X 15 DAYS

T.REJUNEX CD3 PO/OD X 15 DAYS

SYP.LUPITUSS 10ML PO/TID X 1 WEEK

FORACORT 200MCG MDI SPACER 2PUFS TWICE DAILY X 15 DAYS

Follow Up

REVIEW TO GM OPD AFTER 1 WEEK OR SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language

CASE NO : 45

86years/FEMALE

D. O. A : 26/10/2024

D. O. D : 1/11/2024

Diagnosis

1) ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE(LONG STANDING)

2)B/L LOWER LOBE PNEUMONIA (RESOLVING)

3)HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF=48%) WITH MILD LV

DYSFUNCTION

4)URINARY TRACT INFECTION.

5)K/C/O HYPERTENSION SINCE 30 YEARS

Case History and Clinical Findings

C/O COUGH SINCE 7 DAYS

C/O SOB SINCE 7 DAYS

C/O FEVER SINCE 7 DAYS

HOPI :

PATIENT WAS APPARENTLY ASYMTOMATIC 7 DAYS AGO AFTER WHICH SHE DEVELOPED

FEVER LOW GRADE NOT ASSOCIATED WITH CHILLS AND RIGOR , INSIDIOUS IN ONSET

GRADUALLY PROGRESSIVE

C/O SOB (GRADE III MMRC ) SINCE 7 DAYSINSIDIOUS IN ONSET GRADUALLY PROGRESSIVE

, NO AGRREVATING AND RELIEVING FACTORS

C/O COUGH SINCE 7 DAYSINSIDIOUS IN ONSET GRADUALLY PROGRESSIVE ASSOCIATED

WITH SPUTUM , NO AGREVATING ANDRELIEVING FACTORS

H/O BURNING MICTURITION SINCE 1 MONTH OCCASIONALLY

H/O PEDAL EDEMA 5 YEARS AGO (1 EPISODE)

NO H/O FACIAL PUFFINESS

NO H/O CHEST PAIN, CHEST TIGHTNESS, LOOSE STOOLS

PAST HISTORY :

K/C/O HTN SINCE 12 YEARS

N/K/C/O DM,TB, CVA, CAD, EPILEPSY, THYROID

PERSONAL HISTORY :

DIET - MIXED

APPETITE - NORMAL

SLEEP - ADEQUATE

BOWEL& BLADDER MOVEMENTS - IRREGULAR SINCE 2 YEARS

ADDICTIONS: CHEWS TOBACCO OCCASIONALLY 1 PER DAY SINCE 60 YEARS

GENERAL EXAMINATION:

PT IS C/C/C

NO VISIBLE SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY,

PEDAL EDEMA

TEMP: AFEBRILE

PR: 126 BPM

RR: 30 CPM

BP; 160/100 MMHG

SPO2: 96% @ RA

GRBS : 152 MG%

SYSTEMIC EXAMINATION:

CVS-JVP NOT RAISED. S1, S2 PRESENT , NO MURMURS,

 CHEST WALL - SYMMETRICAL, ELLIPTICAL IN SHAPE

 NO DILATED VEINS

 APICAL IMPULSE : AT 5TH INTERCOASTAL SPACE 4CM LATERAL TO MID CLAVICULAR LINE

 PALPATION :APICAL IMPULSE NORMAL , PALPABLE AT 5TH INTERCOASTAL SPACE 1

CMLATERAL TO MID CLAVICULAR LINE

AUSCULTATION:S1, S2+, NO MURMURS

RSBAE+, CRYPTS IN RT ISA, IAA

PER ABDOMEN : SOFT , TENDERNESS IN SUPRAPUBIC REGION

CNS- CONSCIOUS, PUPILS-NSRL

E4V5M6

SENSORY SYSTEM: R L

CRUDE TOUCH INTACT INTACT

FINE TOUCH INTACT INTACT

PAIN INTACT INTACT

TEMPERATURE INTACT INTACT

VIBRATION INTACT INTACT

POSITION SENSATION INTACT INTACT

ROMBERGS ABSENT ABSENT

STERIOGNOSIS NORMAL NORMAL

REFLEXES BICEPS TRICEPS SUPINATOR KNEE ANKLE

RIGHT 2+ 2+ +1 2+ +1

LEFT 2+ 2+ +1 2+ +1

PLANTAR RESPONSERIGHT-FLEXOR

LEFT-FLEXOR

FINGER NOSE AND KNEE HEEL INCOORDINATION: NO

NORMAL GAIT

FINGER NOSE INCOORDINATION : NO

KNEE HEEL INCOORDINATION : NO

Investigation

COMPLETE URINE EXAMINATION (CUE) 26-10-2024 12:37:AM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN Nil

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 2-3

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

Anti HCV Antibodies - RAPID 26-10-2024 12:37:AM Non Reactive

HBsAg-RAPID 26-10-2024 12:37:AM Negative

RFT 26-10-2024 12:37:AM

UREA 18 mg/dl 50-17 mg/dl

CREATININE 0.9 mg/dl 1.2-0.6 mg/dl

URIC ACID 6.0 mmol/L 6-2.6 mmol/L

CALCIUM 9.9 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.4 mg/dl 4.5-2.5 mg/dl

SODIUM 135 mmol/L 145-136 mmol/L

POTASSIUM 3.8 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 97 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 26-10-2024 12:37:AM

Total Bilurubin 0.98 mg/dl 1-0 mg/dl

Direct Bilurubin 0.16 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 26 IU/L 31-0 IU/L

SGPT(ALT) 15 IU/L 34-0 IU/L

ALKALINE PHOSPHATASE 196 IU/L 141-53 IU/L

TOTAL PROTEINS 7.3 gm/dl 8.3-6.4 gm/dl

ALBUMIN 3.7 gm/dl 4.6-3.2 gm/dl

A/G RATIO 1.06

SERUM ELECTROLYTES (Na, K, C l) 27-10-2024 09:57:AM

SODIUM 135 mmol/L 145-136 mmol/L

POTASSIUM 3.7 mmol/L 5.1-3.5 mmol/L

CHLORIDE 100 mmol/L 98-107 mmol/L

SERUM ELECTROLYTES (Na, K, C l) 27-10-2024 11:54:PM

SODIUM 136 mmol/L 145-136 mmol/L

POTASSIUM 3.6 mmol/L 5.1-3.5 mmol/L

CHLORIDE 98 mmol/L 98-107 mmol/L

HEMOGRAM DONE ON 31/10/24 5:50 AM

HAEMOGLOBIN: 13.4 MG/DL

TLC: 11,400 cells/cumm

NEUTROPHILS : 86 %

LYMPHOCYTES: 08%

EOSINOPHILS: 01%

MONOCYTES: 05%

PCV: 38.8%

MCV: 76.9 fl

MCH: 26.6 pg

MCHC: 34.6%

RDW-CV 14.9

RBC COUNT: 5.04 millions/cumm

PLATELET COUNT: 2.0 lakhs/cu.mm

SMEAR : Normocytic normochromic

HEMOGRAM DONE ON 1/11/24 5:50 AM

HAEMOGLOBIN: 12.5 MG/DL

TLC: 11,000 cells/cumm

NEUTROPHILS : 78 %

LYMPHOCYTES: 13%

EOSINOPHILS: 01%

MONOCYTES: 08%

PCV: 35.6%

MCV: 75.5 fl

MCH: 26.7 pg

MCHC: 35.6%

RDW-CV 15.1

RBC COUNT: 4.69 millions/cumm

PLATELET COUNT: 2.0 lakhs/cu.mm

SMEAR : Normocytic normochromic

ECG FINDINGS: Irregularly irregular with absent P waves

USG ABDOMEN AND PELVIS WAS DONE IN 26-10-24:

LIVER- 12.1 CMS NORMAL SIZE AND INCREASED ECHOTEXTURE, NOF/L, NO IHBRD

PV AND CBD NORMAL

GALL BLADDER-CONTRACTED

PANCREAS- OBSERVED BY BOWEL GAS

SPLEEN-8CM NORMAL SIZE AND ECHOTEXTURE

RIGHT KIDNEY-9.3X4.1 CMS, PCS, UPPER URETER-DILATED, REST-OBSCURED, NORMAL

SIZE AND ECHOTEXTURE, CMD+

LEFT KIDNEY-9.4X4.2 CMS,PCS PROMINENT, NORMAL SIZE AND ECHOTEXTURE, CMD+

AORTA I.V.C - OBSERVED BY BOWEL GAS

NO ASCITIS

NO LYMPHADENOPATHY.

DISTENDED U.BLADDER.

UTERUS-POST MENOPAUSAL STATUS.

OVARIES-NOT VISUALISED

IMPRESSION : MILD RIGHT HYDRONEPHROSIS

BILATERAL GRADE 1 FATTYY LIVER

USG CHEST: DONE ON 31/10/24

E/O MILD FREE FLUID NOTED IN RIGHT PLEURAL SPACE WITH UNDERLYING LUNG

COLLAPSE AND AIR BRONCHOGRAMS

NO E/O ANY FREE FLUID NOTED IN LEFT PLEURAL SPACE

IMPRESSION:

MILD RIGHT PLEURAL EFFUSION WITH CONSOLIDATION AND UNDERLYING LUNG

COLLAPSE

2-D ECHO WAS DONE ON 26-10-24.

TACHYCARDIA DURING STUDY

CONCENTRIC LVH +(1.32CMS)

GLOBAL HYPOKINESIA

MILD MR+(MR JET AREA 3.2 CM2)(ECCENTRIC MR+)

MODERATE TR+ WITH PAH(RSVP=45+10=55 MMHG)ECCENTRIC TR+

CALCIFIED AV: MV-MAC+; NO MS/AS.

IAS-INTACT/ANEURYSM

EF=48% MILD LV DYSFUNCTION+

GRADE I DIASTOLIC DYSFUNCTION+

IVC SIZE(1.78 CMS) DILATED NON COLLAPSING.

MILS DILATED RA/RV

Treatment Given(Enter only Generic Name)

1) TAB AUGMENTIN 625 MG PO/TID 1-1-1

2) TAB RIVAROXABAN 10 MG PO/OD 8 PM AFTER FOOD

3) TAB DILTIAZEM 30 MG PO/BD PO/BD 1-0-1

4) TAB AMIODARANE 100 MG PO/BD 1-0-1

5) TAB TELMA 40 MG PO/OD 8AM

6)TAB ECOSPRIN 75/20 MG PO/HS

7) TAB LASIX 2 MG PO/OD 1-0-0

8) TAB PAN 40 MG PO/OD BBF 8AM 1-0-0

9)TAB PCM 650 MG PO/SOS

10)SYP ALKALINE B6 15 ML PO/8D

11)SYP ASCORYL -D 10 ML PO/TID

12)ZYTEE GEL L/A BD

Advice at Discharge

1) TAB AUGMENTIN 625 MG PO/TID X 5 DAYS

2) TAB RIVAROXABAN 10 MG PO/OD TO CONTINUE AT 8PM AFTER FOOD

3) TAB DILTIAZEM 30 MG PO/BD PO/BDTO CONTINUE

4) TAB AMIODARONE 100 MG PO/BDTO CONTINUE

5) TAB TELMA 40 MG PO/ODTO CONTINUE AT 8 AM 1-0-0

6)TAB ECOSPRIN 75/20 MG PO/HSTO CONTINUE AT 8 PM

7) TAB LASIX 20 MG PO/ODTO CONTINUE 1-0-0 AT 8 AM

8) TAB PAN 40 MG PO/OD BBF X 5 DAYS 1-0-0 AT 8 AM BBF

9)TAB PCM 650 MG PO/SOS X 5 DAYS

10)SYP ALKASTONE B6 15 ML PO/BD X 5 DAYS

11)SYP ASCORYL -D 10 ML PO/TID X 5 DAYS

12)ZYTEE GEL L/A BD X 5 DAYS

Follow Up

REVIEW TO GM OPD AFTER 2 WEEKS OR SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

 

CASE NO : 46

80years/MALE

D. O. A : 07/10/2024

D. O. D : 11/10/2024

Diagnosis

1. RIGHT HEMIPARESIS SECONDARY TO ACUTE INFARCT IN FRONTO-PARIETAL LOBE.

2. CHRONIC INFARCT IN LEFT CEREBELLAR HEMISPHERE, CHRONIC ISCHEMIC INFARCT IN

RIGHT PARIETAL LOBE

3. CHRONIC MICROVASCULAR ICHEMIA IN B/L PARIETAL DEEP WHITE MATTER

4. MICROHAEMORRRHAGES IN RIGHT CORONA RADIATA

5. CARDIAC EMBOLIC STROKE SECONDARY TO PAROXYSMAL AF

6. PRE RENAL AKI (RESOLVING)

Case History and Clinical Findings

CHEIF COMPLAINTS :

C/O WEAKNESS OF RIGHT UPPER AND LOWER LIMBS, DEVIATION OF MOUTH TO LEFT SIDE

SINCE 3 DAYS

HISTORY OF PRESENTING ILLNESS:

PATIENT WAS APPARENTLY NORMAL 3 DAYS BACK.

THEN HE DEVELOPED SUDDEN ONSET OF WEAKNESS OF RIGHT UPPER AND LOWER

LIMBS (SINCE 5 AM THAT DAY) AND ASSOCIATED WITH DEVIATION OF MOUTH TO LEFT

SIDE, WITH DROOLING OF SALIVA.

C/O DIFFICULTY IN SWALLOWING SINCE THEN.

C/O INVOLUNTARY MICTURITION DURING THE WEAKNESS.

C/O SLURRING OF SPEECH SINCE THEN.

NO C/O NAUSEA,VOMITINGS, INVOLUNTARY MOVEMENTS OF UL &LL, LOC, INVOLUNTARY

DEFECATION , HEADACHE.

NO C/O CHEST PAIN, SOB, PALPITATIONS, GIDDINESS, SWEATING.

PAST HISTORY :

PATIENT IS N/K/C/O DM, HYPETENSION, TB, EPILEPSY, CVA, CAD, THYROID DISORDER,

BRONCHIAL ASTHMA.

NO H/O SIMILAR COMPLAINTS IN THE PAST.

GENERAL EXAMINATION :

NO PALLOR, ICTERUS, CLUBBING, KOILONYCHIA, LYMPHEDENOPATHY, EDEMA.

TEMP : AFEBRILE

PR: 88 BPM

BP: 130/80 MMHG

RR: 20 CPM

GRBS: 123 MG%

SYSTEMIC EXAMINATION :

CVS: S1S2 HEARD

RS: BAE + NVBS HEARD

P/A: SOFT, NON TENDER

CNS:

HIGHER MENTAL FUNCTIONS: CONCIOUS, NOT OREIENTED TO TIME, PLACE, PERSON

CRANIAL NERVES:

FACIAL : DEVIATION OF MOUTH TO LEFT SIDE.

REST OF THE CRANIAL NERVES : NOT ABLE TO ELICIT

MOTOR SYSTREM :

BULK RIGHT LEFT

UPPER LIMB

MA 32CM 32CM

FA 29 CM 29CM

LOWER LIMB

MT 38CM 38CM

L 34CM 34CM

TONE

UPPER LIMB INCREASED NORMAL

LOWER LIMB INCREASED NORMAL

POWER

UPPER LIMB 2/5 4/5

LOWER LIMB 2/5 4/5

REFLEXES

B 2+ 3+

T 2+ 3+

S - 3+

K 2+ 3+

A - -

P F F

CARDIOLOGY REFFERAL DONE ON 08-10-24

ADV.

1. INJ. CARDARONE 150MG IV BOLUS OVER 10 MIN --> INJ CORDARONE 1MG/MIN X 6 HRS-->

0.5 MG/MIN X 15 HOURS

2. INJ HEPARIN 5000IU / IV/QID

3. TAB ECOSPRIN AV (75/40) OD

4. TAB METXL 50MG/OD

5. INJ LASIX 20MG IV / TID

6. TAB CORDARONE 200MG / BD/ AFTER INFUSION

COURSE IN THE HOSPITAL

A 78 YEAR OLD MALE CAME WITH COMPLAINTS OF DYSPHAGIA AND RIGHT SIDED

WEAKNESS OR UL AND LL SINCE 3 DAYS. ON EXAMINATION VITALS WERE STABLE AND THE

REFLEXES WERE EXAGGERATED WITH BILATERAL PLANTAR FLEXOR AND ON FURTHER

EVALUATION THR PATIENT MRI REPORT SHOWED

- LARGE ACUTE INFARCT IN LEFT PARIETAL LOBE WITH SMALL EXTENSION INTO LEFT

POSTERIOR FRONTAL LOBE AND INSULAR CORTEX.

- CHRONIC INFARCT IN LEFT CEREBELLAR HEMISPHERE

- CHRONIC ISCHEMIC INFARCT IN RIGHT PARIETAL LOBE

- FEW CONFLENT AND FEW DISCRETE FLAIR HYPERINTENSE FOCI IN B/L PARIETAL DEEP

WHITE MATTER AND LEFT CORONA RADIATA- S/O CHRONIC MICROVASCULAR ISCHEMIA.

- FEW MICRO HAEMORRHAGES IN RIGHT CORONA RADIATA, CENTRUM SEMI OVALEAND

LEFT FRONTAL SUB CORTICAL WHITE MATTER

AND RENAL PARAMETERS WERE SUGGESTING PRERENAL AKI AND CONSERVATIVELY THE

INPUT AND OUTPUT WAS ALSO MAINTAINED AND CREATININE CLEARENCE WAS ALSO

MAINTAINED ON ADMISSION ECG SHOWED VPCS AND FURTHER TOOK CARDIAC OPINION

AND DIAGNISED WITH ATRIAL FIBRILATION WITH FVR AND ADVISED FOR CONSERVATIVE

MANAGEMENT . REPEATED ECGS SHOWING REVERTED SINUS RHYTHM WITH

CONTROLLED RATE AND PATIENT IS TREATED CONSERVATIVELY AND PATIENT IS BIENG

DISCHARGED AT HEMODYNAMICALLY STBLE CONDITION

Investigation

HEMOGRAM :

10-10-24

HAEMOGLOBIN 9.7 gm/dlTOTAL COUNT 19,800 cells/cummNEUTROPHILS 89 %

LYMPHOCYTES 05 % EOSINOPHILS 01 % MONOCYTES 05 %BASOPHILS 00 % PCV 28.1 vol

%M C V 69.7 fl M C H 24.1 pg M C H C 34.5 %RDW-CV 18.7 %RDW-SD 40.7 fl RBC COUNT 4.03

millions/cumMPLATELET COUNT 3.02 lakhs/cu.mm SMEARRBC Normocytic normochromic few

microcytesWBC Increased counts on smear PLATELETS Adequate in number and distribution

HEMOPARASITES No hemoparasites seen IMPRESSION Microcytic hypochromic Anemia

withneutrophilic leucocytosis

HEMOGRAM ON 11/10/24

HAEMOGLOBIN 9.0 gm/dlTOTAL COUNT 14100 cells/cummNEUTROPHILS 82 %LYMPHOCYTES

10 %EOSINOPHILS 01 %MONOCYTES 07 %BASOPHILS 00 %PCV 26.1 vol %M C V 70.4 flM C H

24.1 pgM C H C 34.5 %RDW-CV 18.7 %RDW-SD 40.7 flRBC COUNT 4.03 millions/cumMPLATELET

COUNT 3.02 lakhs/cu.mmSMEARRBC Normocytic normochromic few microcytesWBC Increased

counts on smearPLATELETS Adequate in number and distributionHEMOPARASITES No

hemoparasites seenIMPRESSION Microcytic hypochromic Anemia withneutrophilic leucocytisis

RFT 07-10-2024 12:27:PM

UREA 57 mg/dlCREATININE 1.4 mg/dl URIC ACID 5.4 mmol/L CALCIUM 9.6 mg/dl

PHOSPHOROUS 3.4 mg/dl SODIUM 137 mmol/L POTASSIUM 3.7 mmol/LCHLORIDE 101 mmol/L

RFT ON 11/10/24

UREA 61 mg/dlCREATININE 1.2mg/dlURIC ACID 2.7 mmol/LCALCIUM 8.9 mg/dlPHOSPHOROUS

2.92 mg/dlSODIUM 136 mmol/LPOTASSIUM 3.4 mmol/LCHLORIDE 104 mmol/L

LIVER FUNCTION TEST (LFT) 07-10-2024 12:27:PMTotal Bilurubin 2.98 mg/dl 1-0 mg/dlDirect

Bilurubin 0.72 mg/dl 0.2-0.0 mg/dlSGOT(AST) 21 IU/L 35-0 IU/LSGPT(ALT) 19 IU/L 45-0

IU/LALKALINE PHOSPHATASE 158 IU/L 119-56 IU/LTOTAL PROTEINS 6.9 gm/dl 8.3-6.4

gm/dlALBUMIN 3.5 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.02HBsAg-RAPID 07-10-2024 12:27:PM

Negative

Anti HCV Antibodies - RAPID 07-10-2024 12:27:PM Non ReactiveCOMPLETE URINE

EXAMINATION (CUE) 07-10-2024 12:27:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN ++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS

4-6EPITHELIAL CELLS 3-4RED BLOOD CELLS 6-8CRYSTALS NilCASTS NilAMORPHOUS

DEPOSITS AbsentOTHERS Nil

RFT 08-10-2024 05:37:AMUREA 61 mg/dl 50-17 mg/dlCREATININE 1.3 mg/dl 1.3-0.8 mg/dlURIC

ACID 4.5 mmol/L 7.2-3.5 mmol/LCALCIUM 9.9 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.0 mg/dl 4.5-

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

100 mmol/L 98-107 mmol/LCOMPLETE URINE EXAMINATION (CUE) 08-10-2024

10:41:AMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN

TraceSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED

BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

RFT 10-10-2024 UREA 66 mg/dl 50-17 mg/dlCREATININE 1.3 mg/dl 1.3-0.8 mg/dlURIC ACID 3.4

mmol/L 7.2-3.5 mmol/LCALCIUM 9.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.8 mg/dl 4.5-2.5

mg/dlSODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 3.4 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

104 mmol/L 98-107 mmol/L

COMPLETE URINE EXAMINATION (CUE) 08-10-2024 10:41:AMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN TraceSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

ABG 08-10-2024 10:41:AMPH 7.49PCO2 26.2PO2 72.9HCO3 19.8St.HCO3 22.5BEB -2.2BEecf -

3.0TCO2 40.5O2 Sat 94.0O2 Count 13.4RFT 08-10-2024 11:53:PMUREA 76 mg/dl 50-17

mg/dlCREATININE 1.6 mg/dl 1.3-0.8 mg/dlURIC ACID 3.8 mmol/L 7.2-3.5 mmol/LCALCIUM 9.4

mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.85 mg/dl 4.5-2.5 mg/dlSODIUM 134 mmol/L 145-136

mmol/LPOTASSIUM 3.2 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 102 mmol/L 98-107 mmol/L

D-DIMER : 1610 NG/ML (09-10-24)

USG ABDOMEN AND PELVIS DONE ON 08-10-24 IMPRESSION : B/L/ GRADE 1 RPD CHANGES.

2D ECHO DONE ON 08/10/24 IMPRESSION :

MILD TO MODERATE AR , MILD TR+ WITH PAH, TRIVIAL MR +

NO RWMA. NO AS / MS. CALCIFIED AV.

GOOD LV SYSTOLIC FUCNTION.

GRADE 1 DIASTOLIC DYSFUNCTION. NO PE/LV CLOT.

MRI BRAIN DONE ON 07/10/24

IMPRESSION :LARGE ACUTE INFARCT IN LEFT PARIETAL LOBE WITH SMALL EXTENSION INTO LEFT

POSTERIOR FRONTAL LOBE AND INSULAR CORTEX.

- CHRONIC INFARCT IN LEFT CEREBELLAR HEMISPHERE

- CHRONIC ISCHEMIC INFARCT IN RIGHT PARIETAL LOBE

- FEW CONFLENT AND FEW DISCRETE FLAIR HYPERINTENSE FOCI IN B/L PARIETAL DEEP

WHITE MATTER AND LEFT CORONA RADIATA- S/O CHRONIC MICROVASCULAR ISCHEMIA.

- FEW MICRO HAEMORRHAGES IN RIGHT CORONA RADIATA, CENTRUM SEMI OVALEAND

LEFT FRONTAL SUB CORTICAL WHITE MATTER.

CAROTID DOPPLER 09-10-24

IMPRESSION :

PROXIMAL INTIMAL THICKNESS OF B/L CAROTID ARTERIES.

Treatment Given(Enter only Generic Name)

1. RT FEEDS

50ML WATER 2ND HOURLY

100ML MILK 4TH HOURLY

2. IVF - NS, DNS - 75ML/HR

3. INJ . AMIODARONE INFUSION @0.5MG/MIN

4. INJ. PIPTAZ 2.25G IV/QID

5. INJ. CLINDAMYCIN 600MG IV/OD

6. INJ OPTINEURON 1 AMP IN 100ML IV/OD

8. TAB STROCIT PLUS RT/BD

9. TAB ECOSPRIN GOLD 75/10 RT/HS

10. INJ PERINORM IV/OD

11. TAB PAN 40 RT/OD

12. INJ HEPARIN 5000 IU IV/QID

13. INJ LASIX 20 MG IV/ TID

14. SYP POTCHLOR 15 ML RT/TID

Advice at Discharge

1.RT FEEDS - 50ML WATER 2ND HOURLY

100ML MILK 4TH HOURLY

2.TAB GUDCEF CV 200MG PO/BD X5DAYS

3. TAB ASPIRIN 150MG RT/HS 9PM TO CONTINUE

4. TAB CLOPETAB AV (75/20) 9PM HS TO CONTINUE

5. TAB STROCIT PLUS RT BD 8AM &8PM X 10 DAYS

6. TAB FERRONIA XT RT OD 2PM X 10 DAYS

7. TAB METXL 25MG RT/OD 8AM X 10 DAYS

8. TAB CORDARONE 100MG RT BD 8AM &6PM X 10 DAYS

9. TAB LASIX 20MG RT/OD 8AM X 7 DAYS

10. TAB BACLOFEN 10MG RT/BD 8AM &8PM X 7 DAYS

11. TAB ZINCOVIT RT/OD 2PM X 15 DAYS

12. TAB PAN 40 RT OD

13.TAB.LEVIPIL 500MG PO/OD TO BE CONTINUED

14.PHYSIOTHERAPY FOR RIGHT UPPER AND LOWERLIMB

Follow Up

REVIEW IN MEDICINE OPD ON 21/10/24

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 47

63years/MALE

D. O. A : 04/09/2024

D. O. D : 08/09/2024

Diagnosis

ENCEPHALOPATHY SECONDARY TO NECROTISING FASCITIES OF LEFT LOWERLIMB AND

TO CARDIAC EMBOLIC STROKE

DIABETIC KETOACIDOSIS (RESOLVED) WITH HYPOKALEMIA(RESOLVED)

MULTIFOCAL ATRIAL TACHYCARDIA<------->ATRIAL FIBRILLATION

S/P DEBRIDEMENT AND FASCIOTOMY UNDER LA(POD-3)

K/C/O T2DM(SINCE 10 YEARS),HTN(20 YRS),CVA(SINCE 5 YEARS )

Case History and Clinical Findings

CHIEF COMPLAINTS :

C/O WOUND OVER LEFT THIGH

ALTERED BEHAVIOUR SINCE YESTERDAY

HOPI:

PATIENT WAS APPARENTLY ASYMPOTMATIC 4 DAYS THEN HE DEVELOPED BLEB OVER

LEFT THIGH INSIDIOUS ONSET FOR WHICH HE APPLIED HERBAL MEDICATION THEN IT

RUPTURED AND OOZES FROM BASE FORMS A ULCER INSIDIOUS IN ONSET, GRADUALLY

PROGRESSIVE .PATIENT DEVELOPED SLURRING OF SPEECH WITH DEVIATION OF MOUTH

TO RIGHT WITH WEAKNESS OF LEFT UPPER AND LOWER LIMB SINCE 2 DAYS .PATIENT

INTIALLY WENT TO OUTSIDE HOSPITAL AND CAME HERE FURTHER MANAGEMENT

NO H/O FEVER, COLD, COUGH

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

NO H/O ABDOMINAL PAIN , BURNING MICTURITION, NAUSEA

PAST HISTORY :

K/C/O HTN SINCE 10 YEARS AND ON MEDICATION AMLO-AT 5/50

K/C/O T2DM SINCE 20 YEARS PREVIOUSLY ON INSULIN NOE ON OHA (UNKNOWN)

AT TIME OF ADMISSION :

TEMP:99.6 F

BP: 130/80 MM/HG

PR:108 BPM

RR:20 CPM

SPO2: 100% ON ROOM AIR

GRBS:266MG%

NO ICTERUS, PALLOR, CYANOSIS, CLUBBING, LYMPHADENOPATHY, OEDEMA

CVS : S1S2 +VE, NO MURMURS

RS: BAE+VE, NVBS, NO ADDED SOUNDS

P/A - SOFT, NON TENDER

CNS : E4V5M6

REFLEXES:- RT LT

BICEPS :- +2 +2

TRICEPS :- +2 +2

KNEES :- +2 CANNOT BE ELICITED

ANKLE :- +1 CANNOT BE ELICITED

SUPINATOR:- +1 +1

PLANTAR FLEXION FLEXION

DEATH SUMMARY:

62 YEAR OLD MALE RESIDENT OF NALGONDA WHO IS A KNOWN DIABETIC SINCE 20

YEARS,HTN SINCE 10 YEARS,CVA SINCE 5 YEARS WAS BROUGHT TO THE CASULITY ON

4/9/24 WITH ALTERED SENOSRIUM,WOUND OVER LEFT LOWER LIMB AND WEKNESS OF

LEFT UPPERLIMB AND LEFT LOWER LIMB

HIS GCS AT THE TIME OF PRESENTATION E4V5M6 BUT NOT ORIENTED TO

TIME,PLACE,PERSON.

PATIENT WENT TO OUTSIDE HOSPITAL 3 DAYS AGO WHWRE HE WAS STARTED ON

ANTIBIOTOCS I/V/O LEFT LOWER LIMB CELLULITIS

AT THE TIME OF PRESENTATION VITALS ARE PR-106BPM,BP-130/80MMHG,RR-20CPM,TEMP-

99.6 F,GRBS-266MG%,UKB-+VE I/V/O DKA PATIENT WASSTARTED ON INSULIN LNFUSION

I/V/O WOUND OVER LEFT LEG SURGERY REFERAL WAS TAKEN AND DIAGNOSED AS

NECROTISING FASCITIS.DEBRIDEMENT UNDER LA WAS DONE AND STARTED ON

ANTIBIOTICS

I/V/O LEFT UL AND LL WEAKNESS MRL BRAIN WAS DONE AND HAD MULTIPLE ACUTE

INFARCTS

ON 8/9/24 AT 7:30 AM PATIENT WAS DROWSY BU AROUSABLE AND SAT ON RA 85%.AT 8:30

AM PATIENT HAD SUDDEN BRADYCARDIA AND ABSENT CENTRAL AND PERIPHERAL

PULSES.CPR WAS STARTED ACCORDING TO ACLS GUIDELINES.AFTER 30 MIN OF CPR PT

HAD NO RESPONSE AND DECLARED DEAD AT 9:25AM ON 8/9/24

IMMEDIATE CAUSE:

1)TYPE-1 RESPIRATORY FAILURE WITH SEVERE METABOLIC ACIDOSIS

2)ENCEPHALOPATHY SECONDARY TO NECROTISING FASCITIES LEFT LOWERLIMB AND TO

CARDIAC EMBOLIC STROKE

3)AF<------>MAT

ANTECEDENT CAUSE :

1)NECROTISING FASCITIS OF LEFT LOWER LIMB(S/P DEBRIDMENT UNDER LA)

2)DKA(RESOLVED) WITH HYPOKALEMIA(RESOLVED)

3)K/C/O HTN,DM-II,CVA

Investigation

HAEMOGRAM 04/09/2024

HB- 12.5GM/DL

TLC- 9,200 CELLS/CUMM

N/L/E/M/B: 55/37/02/06/00

PCV: 33.9 VOL%

MCV: 80.1 FL

MCH: 29.6 PG

MCHC: 36.9 %

RBC COUNT: 4.23 M/ CU MM

PLT COUNT: 2.90LAKHS/CU MM

P/S- NCNC

BLOOD GROUP : B POSITIVE (+VE)

RBS 04-09-2024 - 274 MG/DL

FBS 05-09-2024 - 174 MG/DL

HbA1C - 7.3%

ABG 4-09-2024 10:59:PM

PH 7.44

PCO2 25.0 MMHG

PO2 52.1 MMHG

HCO3 19.6 MMOL/L

St.HCO 17.1 MMOL/L

BEB -5.7 MMOL/L

BEecf -6.2 MMOL/L

TCO2 36.4 VOL

O2 Sat 91.7 %

O2 Count 9.9 VOL%

RFT 04-09-2024 05:09:PMUREA 38 mg/dl 42-12 mg/dlCREATININE 1.2 mg/dl 1.1-0.6 mg/dlURIC

ACID 3.1 mmol/L 6-2.6 mmol/LCALCIUM 10.2 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.3 mg/dl 4.5-

2.5 mg/dlSODIUM 137 mmol/L 145-136mmol/LPOTASSIUM 4.3 mmol/L. 5.1-3.5mmol/L.CHLORIDE

104 mmol/L 98-107mmol/L

LIVER FUNCTION TEST (LFT) 04-09-2024 05:09:PMTotal Bilurubin 1.01 mg/dl 1-0 mg/dlDirect

Bilurubin 0.20 mg/dl 0.2-0.0 mg/dlSGOT(AST) 13 IU/L 31-0 IU/LSGPT(ALT) 10 IU/L 34-0

IU/LALKALINE PHOSPHATASE 193 IU/L 98-42 IU/LTOTAL PROTEINS 8.0 gm/dl 8.3-6.4

gm/dlALBUMIN 4.3 gm/dl 5.2-3.5 gm/dlA/G RATIO 1.18

COMPLETE URINE EXAMINATION (CUE) 04-09-2024 05:09:PMCOLOUR Pale yellow

APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010 ALBUMIN + SUGAR ++++ BILE SALTS

Nil BILE PIGMENTS Nil PUS CELLS 3-4 EPITHELIAL CELLS 2-3 RED BLOOD CELLS Nil

CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil

FASTING LIPID PROFILE (4/9/24)

TOTAL CHOLESTROL - 133 MG/DL

TRIGLYCERIDES - 320 MG/DL

HDL CHOLESTROL 28 MG/DL

LDL CHOLESTROL - 72 MG/DL

VLDL - 64 MG/DL

C-REACTIVE PROTIEN (05-09-2024) - POSITIVE(2.4mg/dl)

URINE FOR KETONE BODIES (04/09/2024) - POSITIVE

BLOOD LACTATE 04-09-2024 - 10.1 MG/DL

Anti HCV Antibodies - RAPID 04-09-2024 - Non Reactive

HBsAg-RAPID 04-09-2024 - Negative

HIV 1/2- RAPID 04-09-2024 - NON- REACTIVE

APTT- 32 SEC

BT- 2 MIN

CT- 4MIN 30 SEC

PT- 15 SEC

INR - 1.11

SERUM ELECTROLYTES

SODIUM 138 mmol/L 145-136mmol/LPOTASSIUM 3.7 mmol/L. 5.1-3.5mmol/L.CHLORIDE 106

mmol/L 98-107mmol/L

CALCIUM IONIZED - 1.24 MMOL/L

HAEMOGRAM 06/09/2024

HB- 12.8GM/DL

TLC- 9,300 CELLS/CUMM

N/L/E/M/B: 77/10/03/10/00

PCV: 36.3 VOL%

MCV: 73.4 FL

MCH: 25.6 PG

MCHC: 34.9 %

RBC COUNT: 4.99 M/ CU MM

PLT COUNT: 1.70LAKHS/CU MM

P/S- MICROCYTIC HYPOCHROMIC

HAEMOGRAM 07/09/2024

HB- 9.9GM/DL

TLC- 9,800 CELLS/CUMM

N/L/E/M/B: 78/13/01/08/00

PCV: 29 VOL%

MCV: 74 FL

MCH: 25.4 PG

MCHC: 34.3 %

RBC COUNT: 3.91 M/ CU MM

PLT COUNT: 1.50LAKHS/CU MM

P/S- MICROCYTIC HYPOCHROMIC

HAEMOGRAM 08/09/2024

HB- 9.7GM/DL

TLC- 9,000 CELLS/CUMM

N/L/E/M/B: 83/10/03/04/00

PCV: 29.6 VOL%

MCV: 75.4 FL

MCH: 24.8 PG

MCHC: 32.9 %

RBC COUNT: 3.9 M/ CU MM

PLT COUNT: 1.5LAKHS/CU MM

P/S- NCNC

ABG DONE ON 08/09/24-

PH 7.22

PCO2 31.5 MMHG

PO2 45.4 MMHG

HCO3 12.7 MMOL/L

St.HCO 13.5 MMOL/L

BEB -13.5 MMOL/L

BEecf -13.4 MMOL/L

TCO2 28.1 VOL

O2 Sat 63.5 %

O2 Count 7.5 VOL%

RFT 06-09-2024 05:09:PMUREA 41 mg/dl 42-12 mg/dlCREATININE 1.3 mg/dl 1.1-0.6 mg/dlURIC

ACID 3.2 mmol/L 6-2.6 mmol/LCALCIUM 10mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.1 mg/dl 4.5-2.5

mg/dlSODIUM 139 mmol/L 145-136mmol/LPOTASSIUM 3.5 mmol/L. 5.1-3.5mmol/L.CHLORIDE 104

mmol/L 98-107mmol/L

RFT 07-09-2024 05:09:PM

UREA 48 mg/dl 42-12 mg/dlCREATININE 1.3 mg/dl 1.1-0.6 mg/dlURIC ACID 3mmol/L 6-2.6

mmol/LCALCIUM 10mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.7 mg/dl 4.5-2.5 mg/dlSODIUM 138

mmol/L 145-136mmol/LPOTASSIUM 3.6 mmol/L. 5.1-3.5mmol/L.CHLORIDE 104 mmol/L 98-

107mmol/L

RFT 07-09-2024 05:09:PM

UREA 51 mg/dl 42-12 mg/dlCREATININE 1.8 mg/dl 1.1-0.6 mg/dlURIC ACID 4.2mmol/L 6-2.6

mmol/LCALCIUM 10mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.5 mg/dl 4.5-2.5 mg/dlSODIUM 137

mmol/L 145-136mmol/LPOTASSIUM 3.4 mmol/L. 5.1-3.5mmol/L.CHLORIDE 106 mmol/L 98-

107mmol/L

Death Date

Date:08/09/24.

CASE NO : 48

91years/MALE

D. O. A : 22/07/2024

D. O. D : 24/07/2024

Diagnosis

IMMEDIATE CAUSESEPTIC SHOCK

SEVERE METABOLIC ACIDOSIS(HMGMA)

ANTECEDENT CAUSESEPSIS SECONDARY TO LEFT LOWER LIMB CELLULITIS WITH MODS

ATRIAL FIBRILLATION WITH FVR

HFpEF SECONDARY TO CAD

RECURRENT HYPOGLYCEMIA

Case History and Clinical Findings

CHEIF COMPLAINTSC/O DIFFUSE SWELLING OF LEFT LOWER LIMB SINCE 3 DAYS

C/O FEVER 1 DAY BACK

C/O SOB SINCE 3 HOURS

HISTORY OF PRESENTING ILLNESSPATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS BACK THEN HE DEVELOPED DIFFUSE

SWELLING OF LEFT LOWER LIMB SINCE 3 DAYS DIFFUSE SWELLING AND BLEBS ALL OVER

THE LEFT LOWER LIMB WHICH GOT BURST AND EROSIONS FORMED.H/O SWELLING OF

PENIS AND UNABLE TO PASS URINE SINCE 1 DAY .H/O SOB SINCE 3 HOURS

NO H/O VOMITINGS,DIARRHOEA

NO H/O BOWEL AND BLADDER ABNORMALITIES

NO H/O BLEEDING MANIFESTATION.

PAST HISTORYN/K/C/O DM,HTN,ASTHMA,CAD,THYROID,EPILEPSY

PERSONAL HISTORYDIET-MIXED

APPETITE-NORMAL

SLEEP- ADEQUATE

BOWEL AND BLADDER ABNORMALITIES-URINE NOT PASSED SINCE 1 DAY

ADDICTIONS-NIL

GENERAL EXAMINATIONPT IS C/C/C

NO VISIBLE SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

EDEMA PRESENT IN LEFT LOWER LIMB

TEMP: AFEBRILE

PR: 84BPM

RR: 20CPM

BP: 90/60MM HG

SPO2: 98% @8LTRS O2

GRBS: 49 MG /DL

SYSTEMIC EXAMINATION:

CVS: S1 S2 HEARD

CNS: NFND GCS-E4V3M6

RS: BAE+,NVBS

P/A: SOFT,NON TENDER

LOCAL EXAMINATION OF LEFT LOWER LIMBINSPECTIONDIFFUSE SWELLING OF LEFT LOWER LIMB FROM FOOT TO THIGH

WHITISH DISCOLOURATION OF TISSUE PEELEDOFF SKIN

MULTIPLE BLEBS WHICH ARE RUPTURED OVER MEDIAL ASPECT OF THIGH

TOTAL 4 OF ECH MEASURING 3X4CM

ERYTHEMA OVER THIGH PRESENT

EDEMA OF PENIS PRESENT

PALPATIONNO LOCAL RISE OF TEMPERTURE

TENDERNESS PRESENT FROM LEFT FOOT TO THIGH

ALL INSPECTORY FINDINGS ARE CONFIRMED

PITTING EDEMA GRADE III

PULSES-RIGHT LEFT

DPA- ++ --

ATA- ++ --

PTA- ++ --

PA ++ --

SURGERY REFERRAL I/V/O CELLULITIS OF LEFT LOWER LIMB

DRESSING WAS DONE ON 22/7/24

REDDISH DISCOLOURATION OF SKIN EXTENDING FROM GROIN WITH WHITISH

PATCHESOVER DORSUM OF FOOT,PENILE EDEMA +,MULTIPLE RUPTURED

BLEBS+,PEELING OF SKIN+

COLD TEMPERATURE EXTENDING FROM DISCOLOURATION OF FOOT TOM GROIN,NON

TENDER

PERIPHERAL PULSES-+

DEBRIBEMENT NOTES DONE ON 23/7/24

A 2CM INCISION GIVEN OVER DORSUM OF PENIS ,NO ACTIVE BLEED

ON 24/7/24

ON DRE- ANAL SPHINCTER NORMAL,RECTUM LOADES WITH STOOL PELLETS,RECTAL

STIMULATION DONE

ADVISED-PROCTOLYSIS/SOAP WATER ENEMA

CARDIOLOGY REFERRAL I/V/O ATRIAL FIBRILLATION

ADVISED- INJ.CARDARONE 150MG/IV/BOLUD OVER 10MINS,INJ.CARDARONE 1MG/MIN FOR 6

HOURS,TAB.CARDARONE 200MG TID,TAB.METXL 50MG/OD,INJ.LASIX 20MG

IV/TID,INJ.HEPARIN 5000IU/IV/TID,TAB.ECOSPIRIN AV OD

NEPHROLOGY OPINION WAS TAKEN I/V/O DECRESED URINE OUTPUT AND DERRANGED

RFT.

Investigation

HEMOGRAM

 22/7 23/7 24/7

HB- 11.9 10.9 10.3

TLC-16,800 22,950 33,500

N/L/M/E/B

36/25/38/0.1/0 93/2/0/5/0 90/8/0/2/0

RBC- 4.11 3.73 3.46

PLT- 1.1LAKH 1.6 LAKH 72,000

RFT

 22/7 23/7 24/7

UREA 137 147 158

CREATININE- 3.3 3.5 3.7

URIC ACID- 7 7.6 8.4

CALCIUM- 9.2 9.1

PHOSPHORUS- 5.4 4.8

SODIUM- 135 138

POTASSIUM- 3.5

CHLORIDE 98

LFT- 22/7

TOTAL BILIRUBIN- 3.18

DIRECT BILIRUBIN- 2.02

ALT- 137

ALP-176

ALBUMIN- 2.33

A/G- 0.98

LDH- 579

RBS- 70

 23/7 24/7APTT-34SEC 35SEC

PT-17SEC 18SEC

INR-1.25 1.33

ESR-60

CRP-1.2 POSITIVE

BGT-O +VE

RETIC COUNT- 0.8

AV DOPPLERNO DVT

ALL THE EXAMINED ARTERIES SHOW NORMAL CALIBRE,COLOURUPTAKE,PULSATING AND

NORMAL TRIPHASIC WAVEFORMS EXCEPT POPLITEAL ARTERY,ATV,PTV,DPV WHICH SHOW

BIPHASIC WAVEFORMS

ALL THE EXAMINED VEINS APPEAR NORMAL

SUBCUATNEOUS EDEMA OF ENTIRE LEFT LOWER LIMB

USGE/O MILD FREE FLUID NOTED IN RIGHT AND LEFT PLEURAL SPACES WITH UNDERLYING

LUNG COLLAPSE AND AIR SONOGRMS.

E/O 34X30MM CYST NOTED IN THE UPPER POLE OF LEFT KIDNEY

IMPRESSIONB/L MILD PLEURAL EFFUSION WITH UNDERLYING LUNG COLLAPSE AND CONSOLIDATION

RAISED ECHOGENICITY OF LEFT AND RIGHT KIDNEYS

LEFT SIMPLE RENAL CORTICAL CYST.

2D ECHOATRIAL FIBRILLATION UNDER STUDY

RWMA +LAD HYPOKINESIA,CONCENTRIC LVH +(1.32CM),MAC+,MODERATE MR+,CALCIFIED

AV ,MODERATE AR+,MODERATE TR WITH PAH,NO AS/MS,EF-54%,,IVC SIZE 1.63CM DILATED

NON COLLAPSING,MILD TO MODERATE PR+,DILATED LA/RA,MILD PE

Treatment Given(Enter only Generic Name)

RYLES FEEDS 100ML WATER 2ND HRLY 100ML MILK +PROTEIN POWDER 4TH HRLY

IVF NS,DNS@75ML/HR

INJ.AMIODARONE 6ML +44ML NS IV @5ML/HRX18HRS

INJ.LINEZOLID 600MG IV/BD

INJ.PIPTAZ 2.25G IV/TID

INJ.METROGYL 500MG IV/BD

INJ.PAN 40MG IV/OD

INJ.LASIX 20MG IV/TID

TAB.ECOSPIRIN AV 75/20 RT/HS

REGULAR LEFT LL DRESSINGS

TAB.SODIUM BICARBONATE 500MG RT/TID

TAB.CARDARONE 200MG RT/OD

Follow Up

DEATH SUMMARY-

A 90 YEAR OLD MALE PATIENT BROUGHT TO THE CASUALITY WITH C/O SWELLING OF LEFT

LOWER LIMB SINCE 3 DAYS WITH A TRAUMA H/O 3 DAYS BEFORE FOR THAT H/O FEVER

MILD GRADE FOR 1 DAY GOT RELIEVED ON MEDICATION.H/O SOB SINCE 3 HOURS WITH NO

COMORBIDITIES AND HABITS.PATIENT WAS FIRST EXAMINED IN THE CASUALTY BY

SURGERY PEOPLE AND MEDICAL DMO AND FOUND HYPOGLYCEMIC WITH GRBS 49MG/DL

AND WAS GIVEN 25%DNS BY MEDICAL DMO AND SUGARS IMPROVED TO 142MG/DL.THEN

WITH H/O NOT PASSING STOOLS AND URINE PATIENT WAS FOLEYS CATHERISED BY

SURGEONS WITH FORCEPS.THEN AFTER DISCUSSING WITH PG-3 AND SR BY OUR PG-3 AS

THE PT IS UNSTABLE WITH LOW SATURATION 98%UNDER 8LTRS OF O2 THEY ASKED TO

STABILIZE THE PT FIRST BY TAKING TO MEDICAL ICU AS THEIR IS NO SURGICAL ACTIVE

INTERVENTION UNTIL PT GOT STABILISED.PT WAS ADMITTED TO MEDICAL ICU AND

NECESSARY INVESTIGATIONS WERE MADE.BY THIS TIME THE SURGERY TEAM MADE

FASCIOTOMY NICKS OVER THE LEFT LOWER LIMB AT THE CASUALTY ITSELF AFTER

INVESTIGATIONS WITH THEIR SR PRESENCE AND ASKED TO CONTINUE SAME TREATMENT

AS PER TREATING TEAM.ON EXAMINING THE CASE IN ICU WE FOUND HIS BP-90/60 WITH

SPO2 98% UNDER 8 LTRS OF O2 PR-84BPM WITH NO ADDITION BREATH SOUNDS OR

MURMURS WITH P/A RIGID AND TENDER .UNDER THE GUIDANCE OF PG-3 AND SR INITIALLY

PT WAS STARTED ON PIPTAZ AND METRONIDAZOLE ANTIBIOTICS AND ON AMIADARONE

AND SODIUM BICARBONATE(PH-7.28,PCO2-30.1,PO2-68.9,HCO3-13.6).ON DAY 2 WITH 2D

ECHO SHOWING RWMA+,LAD HYPOKINESIA,CONCENTRIC LVH+(1.32CM) MODERATE MR,AR

WITH IVC SIZE (1.63CM) DILATED NON COLLAPSING AND MILD PE+,NO LV CLOT,DILATED

LA/RA.ON DAY 2 WITH CARDIOLOGY ADVISED WE CONTINUED AMIODARONE IV AND ADDED

LINEZOLID AS HIS COUNTS INCREASED TO 22,950 .A 2CM INCISION GIVEN OVER DORSUM

OF PENIS WITH NO ACTIVE BLEED (NOTES AS PER DOCUMENTED BY SURGERY DEPT).PT

WAS FOUND WITH REDDISH DISCOLOURATION OVER THE ABDOMEN BELOW UMBILICUS

EXTENDING FROM THIGH TO UMBILICUS WITH UREA-158,CREATININE-3.7,URIC ACID-

8.4,SODIUM-138,POTASSIUM-3.5,CHLORIDE-98,PT-17SEC,INR-1.25,ESR

-60,CRP-1.2.PT WAS TAKEN FOR NEPHRO OPINION I/V/O RAISED CREATININE AND

UREA.AND IT WAS INFORMED TO THE SURGERY DEPARTMENT FOR REVIEW AND OPINION

ON NON-PASSING STOOLS AND REDUCED URINE OUTPUT AND SKIN

DISCOLOURATION.SURGEONS EXAMINED THE CASE AND SUGGESTED TREATMENT AS

PER TREATING PHYSICIAN AND PROCTOLYSIS ENEMA/SOAP WATER ENEMA.PT WAS

EXAMINED FOR FUTHER TREATMENT AND FOUND HYPOTENSIVE AND HIS KIDNEY

GETTING COMPROMISED AND AMIODARONE WAS STOPPED ON ADVISE OF SR.AT 13:00 PM

PT SATURATIONS GOT DROPPED SUDDENLY FROM 96% UNDER 6LTRS OF O2 TO

84%UNDER 6LTRS OF O2 AND BP FOUND TO BE HYPOTENSIVE,WAS INTUBATED

IMMEDIATELY BY PG-2 AND ICU PG AND WAS TAKEN TO MECHANICAL VENTILATION BUT

THE PT CANNOT REVIVED RISK WAS EXPLAINED AND CONSENT WAS TAKEN AFTER

EXPLAINING OUTCOMES AND COMPLICATIONS.CPR WAS PERFORMED FOR 6 CYCLES WITH

6 DOSES OF ADRENALINE BUT PT NOT REVIVED AND DECLARED DEATH.

Death Date

Date:24/7/24.

CASE NO : 49

66years/FEMALE

D. O. A : 14/03/2024

D. O. D : 22/03/2024

Diagnosis

SEPTIC SHOCK (RESOLVED) SECONDARY TO LEFT LOWER LIMB CELLULITIS

ALTERED SENSORIUM SECONDARY TO ?SEPTIC &?UREMIC

ENCEPHALOPATHY(RESOLVED)

ATRIAL FIBRILLATION WITH FVR(PAROXYSMAL) REVERTED

AKI (PRE RENAL) ON CKD

ANEMIA (NC/NC) SECONDARY TO CHRONIC DISEASE

HYPERTENSION SINCE 3 YEARS;H/O CVA (LEFT HEMIPARESIS) 18 YEARS AGO

S/P 3 SESSIONS OF HEMODIALYSIS

Case History and Clinical Findings

COMPLAINT OF THORN PRICK TO ANTERIOR PART OF LEG X 7 DAYS BACK

C/O FEVER SINCE 4 DAYS

C/O VOMITING SINCE YESTERDAY

HOPI:PT WAS APPARENTLY ASYMPTOMATIC 7 DAYS BACK,THEN SHE ALLEGEDLY

SUSTAINED THORN PRICK TO ANTERIOR PART OF LEG(TIBIAL REGION).WOUND

GRADUALLY PROGRESSED TO ENTIRE LOWER LIMB .H/O FEVER SINCE 4 DAYS,A/W

CHILLS.H/O VOMITING SINCE YESTERDAYNIGHT,NON BILIOUS,NON BLOOD

STAINED,CONTAINS FOOD PARTICLES

PAST HISTORY:K/C/O HTN SINCE 3 YEARS ON UNKNOWN MEDICATION

K/C/O CVA SINCE 2005,LT SIDED HEMIPARESIS RESOLVED AFTER 1 YEAR

N/A/K/C/O T2DM,CAD,TB,EPILEPSY

ON EXAMINATION:

PT IS C/C/C

BP:110/70 MMHG

PR:130BPM

TEMP:98.9F

SPO2:98% @ RA

RR:18CPM

CVS:S1,S2+,NO MURMURS

RS:B/LAE+,B/L BASAL CREPTS +

P/A:SOFT ,NT

CNS:NFND

SURGERY REFERRAL DONE ON 14/3/24 I/V/O SWELLING IN LEFT LOWER LIMB

ASSOSCIATED WITH PAIN

ADVISED

NORMAL DIET

INJ.PIPTAZ 2.25GM IV TID AFTER CHECKING RFT

TAB DOLO 650 MG P/O TID

TAB .CHYMAROL FORTE P/O TID

TAB. PAN 40 MG P/O OD BBF

MGSO4 DRESSINGS

TAB.MVT P/O OD

TAB.VIT C P/O OD

LEFT LOWER LIMB ELEVATION

ANAESTHESIA DONE I/V/O PRE ANAESTHETIC CHECK UP FOR FASCIOTOMY UNDER SPINAL

ANAESTHESIA

MALLAMPATTI GRADE III

ADVISED:

OPTIMISE HB : TO 10 GM/DL

REVIEW PAC

COURSE IN THE HOSPITAL:

A 68 YR OLD FEMALE CAME WITH C/O FEVER SINCE 4 DAYS,VOMITINGS SINCE 1 DAY.H/O

THORN PRICK TO ANTERIOR PART OF LEFT LEG 7 DAYS AGO LEADING TO SWELLING OF

LOWER LIMB.VITALS ON ADMISSION:PR:90BPM IRREGULARLY IRREGULAR BP:100/70 MMHG

ECG WAS TAKEN IT SHOWED ATRIAL FIBRILLATION FOR WHICH RATE CONTROL,RHYTHM

CONTROL &ANTI COAGULATION PROPHYLAXIS WERE GIVEN .TOTAL COUNTS WERE

ELEVATED.FOR WHICH INJ.MEROPENAM INJ.CLINDAMYCIN WERE STARTED I/V/O SEPSIS

SECONDARY TO CELLULITIS .RFT WAS DERANGED ON DAY 3 PT WAS IN ALTERED

SENSORIUM SECONDARY TO ? SEPTIC ?UREMIC ENCEPHALOPATHY .NEPHROLOGIST

OPINION WAS TAKEN I/V/O ACUTE KIDNEY INJURY ADVICED HEMODIALYSIS 3 SESSIONS OF

HEMODIALYSIS &1(.) PRBC TRANSFUSION WERE DONE.AKI RESOLVED .ATRIAL

FIBRILLATION [PAROXYSMAL]REVERTED,SEPSIS RESOLVING ALTERED SENSORIUM

RESOLVED,PATIENT IS CONSCIOUS COHERENT COOPERATIVE.AND VITALS ARE STABLE

AT THE TIME OF DISCHARGE.

Investigation

Name Value RangeHBsAg-RAPID 14-03-2024 Negative

Anti HCV Antibodies - RAPID 14-03-2024 Non ReactiveBLOOD UREA 14-03-2024 132 mg/dl 50-17

mg/dl

SERUM CREATININE 14-03-2024 3.3 mg/dl 1.2-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) 14-

03-2024 SODIUM 137 mmol/L 145-136 mmol/LPOTASSIUM 4.7 mmol/L 5.1-3.5 mmol/LCHLORIDE

98 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 14-03-2024 Total Bilurubin 1.15 mg/dl 1-0 mg/dlDirect Bilurubin 0.27

mg/dl 0.2-0.0 mg/dlSGOT(AST) 30 IU/L 31-0 IU/LSGPT(ALT) 32 IU/L 34-0 IU/LALKALINE

PHOSPHATASE 117 IU/L 141-53 IU/LTOTAL PROTEINS 5.4 gm/dl 8.3-6.4 gm/dlALBUMIN 2.6

gm/dl 4.6-3.2 gm/dlA/G RATIO 0.93COMPLETE URINE EXAMINATION (CUE) 14-03-2024COLOUR

Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 2-4EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

RFT 15-03-2024 UREA 148 mg/dl 50-17 mg/dlCREATININE 3.6 mg/dl 1.2-0.6 mg/dlURIC ACID 9.0

mmol/L 6-2.6 mmol/LCALCIUM 9.3 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 5.2 mg/dl 4.5-2.5

mg/dlSODIUM 137 mmol/L 145-136 mmol/LPOTASSIUM 4.7 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

102 mmol/L 98-107 mmol/LT3, T4, TSH 15-03-2024 08:35:AMT3 0.20 ng/ml 1.87-0.87 ng/mlT4 5.41

micro g/dl 12.23-6.32 micro g/dlTSH 0.20 micro Iu/ml 5.36-0.34 micro Iu/ml

PERIPHERAL SMEAR 15-03-2024 RBC : Normocytic normochromic with few microcytes TC : With in

normal limits DC: increased neutrophils with mild shift to left PLATELET : Adequate (giant platelets)

are seen IMP: Normocytic normochromic anemia with neutrophilic leucocytosisABG 15-03-2024 PH

7.29PCO2 22.9PO2 42.0HCO3 10.7St.HCO3 13.1BEB -14.3BEecf -14.6TCO2 23.1O2 Sat 73.3O2

Count 9. 6

ABG 15-03-2024 PH 7.36PCO2 19.6PO2 93.3HCO3 10.9St.HCO3 14.6BEB -12.6BEecf -13.5TCO2

22.6O2 Sat 94.8O2 Count 14.9RFT 15-03-2024 UREA 169 mg/dl 50-17 mg/dlCREATININE 3.6 mg/dl

1.2-0.6 mg/dlURIC ACID 9.9 mmol/L 6-2.6 mmol/LCALCIUM 10.0 mg/dl 10.2-8.6

mg/dlPHOSPHOROUS 5.4 mg/dl 4.5-2.5 mg/dlSODIUM 145 mmol/L 145-136 mmol/LPOTASSIUM

4.9 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 106 mmol/L 98-107 mmol/L

T3, T4, TSH 15-03-2024 T3 0.26 ng/ml 1.87-0.87 ng/mlT4 4.01 micro g/dl 12.23-6.32 micro g/dlTSH

0.47 micro Iu/ml 5.36-0.34 micro Iu/mlABG 16-03-2024 04:30:PMPH 7.37PCO2 18.8PO2 104HCO3

10.9St.HCO3 14.6BEB -12.6BEecf -13.4TCO2 22.7O2 Sat 95.6O2 Count 13.6

ABG 17-03-2024 PH 7.35PCO2 25.3PO2 30.8HCO3 13.7St.HCO3 15.4BEB -10.8BEecf -10.7TCO2

31.0O2 Sat 62.2O2 Count 3.8RFT 17-03-2024 UREA 153 mg/dl 50-17 mg/dlCREATININE 3.0 mg/dl

1.2-0.6 mg/dlURIC ACID 11.1 mmol/L 6-2.6 mmol/LCALCIUM 10.2 mg/dl 10.2-8.6

mg/dlPHOSPHOROUS 5.1 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 101 mmol/L 98-107 mmol/L

COMPLETE BLOOD PICTURE (CBP) 17-03-2024 HAEMOGLOBIN 7.4 gm/dl 15.0-12.0 gm/dlTOTAL

COUNT 17800 cells/cumm 10000-4000 cells/cummNEUTROPHILS 82 % 80-40 %LYMPHOCYTES

10 % 40-20 %EOSINOPHILS 02 % 6-1 %MONOCYTES 06 % 10-2 %BASOPHILS 00 % 2-0

%PLATELET COUNT 1.0SMEAR Normocytic normochromic anemia with neutrophilic leucocytosis

and thrombocytopenia ADVICE: dengue serology and coagualation profile to rule out viral

etiolosyABG 18-03-2024 PH 7.48PCO2 23.3PO2 87.8HCO3 17.5St.HCO3 20.4BEB -4.8BEecf -

5.3TCO2 37.0O2 Sat 96.1O2 Count 10.5

COMPLETE BLOOD PICTURE (CBP) 19-03-2024 HAEMOGLOBIN 7.1 gm/dl 15.0-12.0 gm/dlTOTAL

COUNT 18000 cells/cumm 10000-4000 cells/cummNEUTROPHILS 77 % 80-40 %LYMPHOCYTES

15 % 40-20 %EOSINOPHILS 01 % 6-1 %MONOCYTES 07 % 10-2 %BASOPHILS 00 % 2-0

%PLATELET COUNT 1.50SMEAR Normocytic normochromic anemia with leucocytosisABG 19-03-

2024 11:10:PMPH 7.50PCO2 25.3PO2 78.9HCO3 19.6St.HCO3 22.1BEB -2.8BEecf -3.1TCO2

41.7O2 Sat 95.9O2 Count 9.6ABG 18-03-2024 05:46:PM

PH7.47PCO224.6PO271.1HCO317.9St.HCO320.1BEB-5.1BEecf-5.1TCO239.1O2 Sat95.4O2

Count7.1

RFT 19-03-2024 UREA 72 mg/dl 50-17 mg/dlCREATININE 1.9 mg/dl 1.2-0.6 mg/dlURIC ACID 8.3

mmol/L 6-2.6 mmol/LCALCIUM 10.2 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.4 mg/dl 4.5-2.5

mg/dlSODIUM 140 mmol/L 145-136 mmol/LPOTASSIUM 4.3 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 99

mmol/L 98-107 mmol/LTreatment Given(Enter only Generic Name)

APTT - 34

BT - 2MIN 30 SEC

CT-5MIN

PT-16SEC

INR-1.11

CBP- 20/3/24

HB-7.1

TC-18,000

PLT-1.50

CBP - ON 21/3/24

HB- 7.4

TC - 22,000

PLT-1.2

RFT -20/3/24

UREA - 72

CREATINE-1.9

URIC ACID -8.3

SODIUM -140

K- 4.3

CL- 99

RFT ON 21/3/24

UREA - 49

CREAT-1.3

PHOSPHOROUS - 5.0

SODIUM- 141

POTASSIUM - 3.4

CHLORIDE-96

2D ECHO

EF- 69 %

GOOD LV SYSTOLIC FUNCTIONS

GRADE 1 DIASTOLIC DYSFUNCTION

NO PE

IVC - 1.12 CMS COLLAPSING

MODERATE TR WITH MILD PAH

MILD AR , MILD MR

SCLEROTIC AV , NO AS /MS

USG

IMPRESSION

B/L GRADE 1 RPD CHANGES

Treatment Given(Enter only Generic Name)

1)IVF-NS,RL,DNS}@100ML/HR

2)inj.meropenam 500mg IV/BD 1-0-1

3)INJ CLINDAMYCIN 600MG TID

4)INJ METROGYL 500MG IV/TID 1-1-1

5)INJ NORADRENALINE(0.16MG) @ 6ML/HR TO MAINTAIN MAP> 65MMHG

6)INJ AMIODARONE 6MG/ML@ 8.2ML/HR TILL FURTHER ORDER

7)INJ HEPARIN 5000IU IV/TID 1-1-1

8)INJ PANTOP 40MG IV/OD/BBF 1-0-0

9)TAB MET-XL 12.5MG PO/BD

10)STRICT I/O CHARTING

11)GRBS MONITORING 2ND HRLY

12)VITALS MONITORING HRLY

13)LT LOWER LIMB ELEVATION

14)T.CHYMORAL FORTE PO/TID 1-1-1

15)T.PCM 650MG PO/TID 1-1-1

16)T.MVT PO/OD 0-1-0

17)INJ LASIX 20MG IV/TID 1-1-1(IF SBP>100MMHG)

18)SYP LACTULOSE 15ML PO/BD 1-0-1

Advice at Discharge

TAB.FAROPENEM 300MG PO/BD FOR 5 DAYS

TAB.METROGYL 400MG PO/TID FOR 5 DAYS

TAB.LASIX 20MG PO/BD X 7 DAYS

TAB.ACITROM 2.5MG PO/OD 1-0-0 X 7 DAYS

TAB.CARDARONE 200MG PO/BD 1-0-0 X 7 DAYS

TAB.PCM 650MG PO/SOS X 7 DAYS

TAB./MVT PO/OD 0-1-0X 7 DAYS

TAB.NODOSIS 500MG PO/BD 1-0-1X 7 DAYS

TAB OROFER-XT 25MG PO/BD 1-0-1X 7 DAYS

TAB.CHYMERAL FORTE PO/TID 1-1-1 X 7 DAYS

OINT THROMBOPHOBE L/A BD 1-0-1 X 7 DAYS

Follow Up

REVIEW AFTER 2 WEEKS TO GM OPD

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.

CASE NO : 50

77years/MALE

D. O. A : 03/03/2024

D. O. D : 13/03/2024

Diagnosis

1.CARDIOGENIC SHOCK(RESOLVED) SECONDARY TO ACS [NSTEMI EVOLVED IN LCX ,RCA

TERRITORY ] WITH ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE(RESOLVING)

2.HEART FAILURE WITH REDUCED EJECTION FRACTION [EF -20 %]

3.? CARDIO RENAL SYNDROME TYPE 1

4.? PRE RENAL AKI ON ? CKD [RESOLVING]

5. RIGHT UPPER LOBE FIBROSIS POST TB SEQUELAE

Case History and Clinical Findings

C/O DIFFICULTY IN BREATHING SINCE 1 MONTH

HOPI

PATIENT WAS APPARENTLY ALRIGH 1 MONTH BACK THEN DEVELOPED DIFFICULTY IN

BREATHING INSIDIOUS ONSET GRADUALLY PROGRESSIVE FROM GRADE 1 TO GRADE 2 TO

GRADE 4 .NOW MMRC

NO H/O BLEEDING MANIFESTATIONS

NO H/O SWEATING ,GIDDINESS

NO H/O BURNING MICTURATION ,SKIN CHANGES ARROUND UMBILICUS

NO H/O FEVER ,COLD ,COUGH

NO CHEST PAIN , PALPITATIONS ,ORTHOPNEA

K/C/O TB 2 YEARS AND 4 YERAS AGO -O MEDICATION FOR 6 MONTHS EACH TIME

N/K/C/O DM , HYPERTENSION, TB, ASTHMA, EPILEPSY.

SMOKES 2-5 CHUTTAS /DAY STOPPED 2 MONTHS AGO

DRINKS 1 BOTTLE OF TODDY DAILY STOPPED 2 MONTHS AGO

ON EXAMINATION

NOPALLOR ICTERUS, CYNOSIS, CLUBBING ,LYMPHADENOPATHY,EDEMA

NO DEHYDRATION

TEMPRATURE 98.3F

PR: 88 BPM

RR: 18 CPM

BP: 100/60MMHG

SPO2: 96% ON RA

SYSTEMIC EXAMINATION:

CVS:S1S2 HEARD , NO MURMURS.

RS :BAE NORMAL, NVBS HEARD

CNS :NO FOCAL NEUROLOGIC DEFICIT

LEVEL OF CONSIOUSNESS: CONSCIOUS

SPEECH : NORMAL

NO NECK STIFFNESS

NO KERNIGS SIGN

CRANIAL NERVES, MOTOR NERVES, SENSORYSYSTEM NORMAL

GLASGOW SCALE: 15/15

Investigation

ABG 03-03-2024 01:14:PM

PH

7.40

PCO2

24.8

PO2

116

HCO3

15.1

St.HCO3

18.4

BEB

-7.5

BEecf

-8.7

TCO2

29.5

O2 Sat

94.5

O2 Count

19.8

COMPLETE BLOOD PICTURE (CBP) 03-03-2024 01:14:PM

HAEMOGLOBIN13.1 gm/dl

17.0-13.0 gm/dl

TOTAL COUNT9500 cells/cumm

10000-4000 cells/cumm

NEUTROPHILS90 %

80-40 %

LYMPHOCYTES04 %

40-20 %

EOSINOPHILS06 %

6-1 %

MONOCYTES00 %

10-2 %

BASOPHILS00 %

2-0 %

PLATELET COUNT

2.02

SMEAR

Normocytic normochromic with neutrophilia

COMPLETE URINE EXAMINATION (CUE) 03-03-2024

06:01:PM

COLOURPale yellow

APPEARANCEClear

REACTIONAcidic

SP.GRAVITY1.010

ALBUMIN+

SUGARNil

BILE SALTSNil

BILE PIGMENTSNil

PUS CELLS3-4

EPITHELIAL CELLS2-3

RED BLOOD CELLSNil

CRYSTALSNil

CASTSNil

AMORPHOUS DEPOSITSAbsent

OTHERSNil

TROP I 62.6 MG /DL

HEMOGRAM

HAEMOGLOBIN 13.5 12.0 - 15.0

TOTAL COUNT 9900 cells/cumm 4000 - 10000

NEUTROPHILS 84 % 40 - 80

LYMPHOCYTES # 06% 20 - 40

EOSINOPHILS 01% 01 - 06

MONOCYTES 09% 02 - 10

BASOPHILS 00 % 0 - 2

PCV # 40.5 vol % 36 - 46

M C V 83.9 fl 83 - 101

M C H 28.2 pg 27 - 32

M C H C 33.4% 31.5 - 34.5

RDW-CV # 15.4 % 11.6 - 14.0

RDW-SD 47.9 fl 39.0-46.0

RBC COUNT 4.79 millions/cumm 3.8 - 4.8

PLATELET COUNT 1.51 lakhs/cu.mm 1.5-4.1

RBC NORMOCYTIC NORMOCHROMIC

WBC ADEQUATE

PLATELETS Adequate

HEMOPARASITES No hemoparasites seen

IMPRESSION microcytic hypochromic anemia with lymphocytosis

PERIPHERAL SMEAR 24-02-2024 05:58:PM

RBC : Microcytic hypochromic with pencil forms,teardrop cells seen

WBC : With in normal limits with Increased lympocytes decreased neutrophiles

PLATELET : Adequate

RETICULOCYTE COUNT-1.5%

RFT 8/3/2024

UREA 115 mg/dl 42-12 mg/dl

CREATININE 1.6 mg/dl 1.1-0.6 mg/dl

URIC ACID 9.2 mg/dl 6-2.6 mg/dl

CALCIUM 10.0 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.9 mg/dl 4.5-2.5 mg/dl

SODIUM 140 mEq/L 145-136 mEq/L

POTASSIUM 3.2 mEq/L 5.1-3.5 mEq/L

CHLORIDE 99 mEq/L 98-107 mEq/L

RFT ON 9/3/24

UREA 117 mg/dl 42-12 mg/dl

CREATININE 1.7 mg/dl 1.1-0.6 mg/dl

URIC ACID 7.4 mg/dl 6-2.6 mg/dl

CALCIUM 9.4 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.5 mg/dl 4.5-2.5 mg/dl

SODIUM 142 mEq/L 145-136 mEq/L

POTASSIUM 3.5 mEq/L 5.1-3.5 mEq/L

CHLORIDE 106 mEq/L 98-107 mEq/L

2D ECHO ON 4/3/24

RWMA +.RC AHYPO KINETIC

CAD WITH LCX AKINETIC TERRITORY

MODERATE TO SEVER MR +[NO MS ]

MR JET 9.91 CM2

MODERATE TO SEVER AR +;NO AS ANEURYSM

PHT =125 M/S

MODERATE TR POSITIVE WITH PAH [ECCENTRIC TR+]

EF=20 %;RVSP =42+10= 52 MM HG

SPECKS OF CALCIFIED TRILEAFLETS AV

MAC +;IAS INTACT

SEVERE LV DYSFUNCTION +;NO PE

GRADE 1 DIASTOLIC DYSFUNCTION +

NO PE

IVC SIZE 2.19 CMS,DILATED NON COLLAPSING

DILATED LA/LA/RA/IVC

MILD DILATED RV

REPAET 2D ECHO

MODERATE TR +;NO APH

IVC COLLAPSING

DILATED L.V/L.A

EF 17 %

USG ABDOMEN AND PELVIS

B/L GRADE II RPD

RIGHT RENAL CORTICAL CYST

Treatment Given(Enter only Generic Name)

1.FLUID RESTRICTION <2L / DAY

2.SALT RESTRICTION <2 GM /DAY

3.IVF 1. DNS @ 30 ML /HOUR

4.INJ LASIX 20 MG IV /TID

5.INJ HEPARIN 5000 IU /S.C /Q.I.D

6.TAB ECOSPORIN GOLD [75/75/20] P/O HG

8.TAB FEBUXOSTAT 40 MG PO/OD

9.TAB DIGOXIN 0.25 MG PO/OD

10.INJ DOBUTAMINE 2 AMP IN 45 ML NS @ 3 ML/HOUR [TAPERED ACCORDING TO M.A.P]

11.INJ NORAD 2 AMP IN 46 ML NS @ 3 ML/HR [TAPERED ACCORDING TO M.A.P]

Advice at Discharge

1.FLUID RESTRICTION <2L / DAY

2.SALT RESTRICTION <2 GM /DAY

4.TAB LASIX 20 MG PO /TID X 10 DAYS

5.TAB RIVOROXABAN 10MG PO/BD X 10 DAYS

6.TAB ECOSPORIN GOLD [75/75/20] P/O HS TO BE CONTINUED

8.TAB FEBUXOSTAT 40 MG PO/OD X 1 WEEK

9.TAB DIGOXIN 0.25 MG PO/OD X 10 DAYS

10.SYP MUCINAC GEL 15 ML IN 1 GALSS OF WATER PO/BD X 10 DAYS

Follow Up

REVIEW TO GM OPD AFTER 10 DAYS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed

and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been

explained to me in my own language.