Cardiac Arrhythmia ProJR (Case 1-25)

The Best Documented ProJR of 2023 Batch

50 THESIS CASES

November 14, 2025

CASE NO - 1

77 years /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

COLOUR Pale yellow

APPEARANCE Clear

  REACTION Acidic

SP. GRAVITY1.010

ALBUMIN+

SUGARNil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS3-4

EPITHELIAL CELLS2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

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 lymphocytes 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:

For Treatment Enquiries Patient/Attendant 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 - 2

71years/ FEMALE

D. O. A : 30/05/2024

D. O. D : 08/06/2024

Diagnosis

PAROXYSMAL ATRIAL FIBRILLATION (RESOLVED)

?CEREBROVASCULAR ACCIDENT ,

AKI ON CKD

?HEART FAILURE WITH REDUCED EJECTION FRACTION

LEFT CLOSED IT FRACTURE OF FEMUR WITHOUT DNVD

K/C/O HYPERTENSION

GRADE 1 BED SORE

Case History and Clinical Findings

C/O HIP PAIN SINCE 5 HOURS

PATIENT WAS APPARENTLY ASYMPTOMATIC 5 HOURS BACK THEN SHE HAD ALLEGED

HISTORY OF SLIP AND FALL THEN SHE DEVELPED LEFT HIP PAIN WHICH IS SUDDEN IN

ONSET, RAPIDLY PROGESSIVE . THE PAIN IS CONTINOUS ,THOBBING IN NATURE ,PAIN IS

AGGREVATED ON MOVEMENTS AND RELIVED ON TAKING REST .H/O TRAUMA SLIP AND

FALL AT HOME AT NARAYANPUR ON 12 PM ON 30/5/24

NO H/O FEVER

ON 4/6/24 AT AROUND 4PM PATIENT DEVELPED SUDDEN LOSS OF SPEECH SINCE 1HOUR

H/O WEAKNESS OF LEFT UPPER LIMB

NO DEVIATION OF MOUTH,LOSS OF CONSCIOUSNESS

NO H/O VOMITINGS,LOOSE STOOLS

NO H/O INVOLUNTARY MOVEMENTS,FROTHING,TONGUE BITE,FROTHING , TONGUE

BITE,UPROLLING OF EYES

NO H/O CHESTPAIN,BREATHLESSNESS,SYNCOPE,ORTHOPNEA

NO H/O FEVER,COUGH,COLD,DECREASED URINE OUTPUT,EXCESSIVE SWEATING,PEDAL

EDEMA.

ON 5/6/24 PATIENT HAD TACHYCARDIA WITH IRREGULAR HEART RATE,ECG SUGGESTIVE

OF ATRIAL FIBRILLATION

K/C/O HYPERTENSION SINCE 8 YEARS ON UNKNOWN MEDICATION

NO H/O CVA,CAD,ASTHMA,TYROID,SEIZURE DISORDER

ALCOHOLIC (TODDY CONSUMPTION) AND STPPED 10 YEARS BACK ,NONSMOKER

ON EXAMINATION PATIENT IS CONSCIOUS , OBEYING COMMANDS , GCS E4V1M6

AFEBRILE, PR:84BPM ,BP 110/80MMHG

CVS: S1 S2 HEARD, NO MURMURS

RS: CREPTS PRESENT IN B/L IAA

CNS: TONE UL: INCREASED , LL:NORMAL

POWER : UL : RT:5/5 LT:4/5

LL: NOT ELICITED DUE TO PAIN

REFLEXES :

BICEPS 3+ 3+

TRICEPS 2+ 2+

SUPINATOR 1+ 1+

KNEE 2+ NOTELICITED

ANKLE NOTELICITED

Investigation

HEMOGRAM

HB:10.7

TC:10,200

PLT:1.4

CUE

ALB : TRACE

SUGAR : NIL

PUS CELLS : 2-3

EPITHELIAL CELLS : 2-3

RFT

UREA :93

CREAT:2.6

SODIUM:136

K+ : 5.2

CHLORIDE : 106

ABG :

PCO2-27.2

PO2- 70.1

SO2- 94.2

HCO3- 13.3

BUN:43.4

BUN/CREAT :16.6

Treatment Given(Enter only Generic Name)

INJ AMIDARONE 150MG IV IN 50ML NS GIVEN SLOWLY AFTER 10 MINUTES

TAB MET-XL 25MG /RT/STAT

IV FLUIDS NS @ 50ML/HOUR

INJ 5D WITH 8 UNITS HUMAN ACTRAPID INSULIN IV/STAT

STRICT I/O CHARTING

MONITOR VITALS AND INFORM SOS

INJ CEFTRIAXONE IGM IV BD

RYLES FEED TO BE ENCOURAGED

Advice at Discharge

LAMA NOTES

PATIENT ATTENDERS HAVE BEEN EXPLAINED ABOUT THE PATIENT CONDITION i.e

PAROXYSMAL ATRIAL FIBRILLATION (RESOLVED),? CEREBROVASCULAR ACCIDENT, AKI ON CKD? HEART FAILURE WITH REDUCED EJECTION FRACTION, LEFT CLOSED IT FRACTURE

OF FEMUR WITHOUT DNVD ,K/C/O HYPERTENSION, GRADE 1 BED SORE. THE NEED FOR

HOSPITAL STAY FOR FURTHER EVALUATION AND MANAGEMENT IN THEIR OWN

UNDERSTANDABLE LANGUAGE AND THEY HAVE UNDERSTOOD. BUT THEY ARE NOT

WILLING FOR FURTHER HOSPITAL STAY AND WANTED TO LEAVE AGAINST MEDICAL

ADVICE AT THEIR OWN RISK

DOCTORS ,HOSPITAL STAFF AND ADMINISTRATION ARE NOT RESPONSIBLE FOR ANY

UNTOWARD EVENTS OUTSIDE THE HOSPITAL.

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: 

For Treatment Enquiries Patient/Attendant 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 

AUGMENTIN AND INJ.METROGYL AND TAB METXL AND ACCORDINGLY .PATIENT IS BEING DISCHARGED IN A HEMODYNAMICALLY STABLE

CONDITION .

Investigation

Name Value Range

Name Value RangePOST LUNCH BLOOD SUGAR 10-06-2024 10:46:AM 138 mg/dl 140-0

mg/dl

RFT 10-06-2024 10:46:AMUREA 24 mg/dl 50-17 mg/dlCREATININE 0.8 mg/dl 1.3-0.8 mg/dlURIC

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

2.5 mg/dlSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.4 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

99 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 10-06-2024 10:46:AMTotal Bilurubin 2.90

mg/dl 1-0 mg/dlDirect Bilurubin 0.58 mg/dl 0.2-0.0 mg/dlSGOT(AST) 38 IU/L 35-0 IU/LSGPT(ALT) 35

IU/L 45-0 IU/LALKALINE PHOSPHATASE 103 IU/L 119-56 IU/LTOTAL PROTEINS 6.4 gm/dl 8.3-6.4

gm/dlALBUMIN 4.1 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.82

COMPLETE URINE EXAMINATION (CUE) 10-06-2024 10:46:AMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE

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

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilHBsAg-RAPID 10-06-

2024 10:46:AM Negative

Anti HCV Antibodies - RAPID 10-06-2024 10:46:AM Non ReactiveSERUM ELECTROLYTES (Na, K,

C l) 11-06-2024 05:21:AMSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.3 mmol/L 5.1-3.5

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

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

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

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

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

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

mmol/L 98-107 mmol/L

Treatment Given (Enter only Generic Name)

1.FLUID RESTRICTION <1.5L/DAY

2.SALT RESTRICTION <2.5 GM/DL

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

4.INJ.LASIX 40MG IV/OD

5.INJ.HAI S/C TID

6.TAB.TELMISARTAN 40MG PO/OD

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

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

9.TAB.ABIRATERONE 500MG PO/OD

10.TAB.VYMADA 50MG PO/OD

11.SYP CREMAFFIN PLUS 15ML PO/STAT

12.TAB.WYSOLONE 5MG PO/OD

15.TAB.DIGOXIN 0.25 MG PO/OD

16.TAB.DABIGATRAN 110MG PO/BD

17.TAB.GLIMI -M1 PO/BD

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

19. ZENFLOX - OZ PO/BD

Advice at Discharge

1.FLUID RESTRICTION <1.5L/DAY2.SALT RESTRICTION <2.5 GM/DL3.TAB . GLIMI M1

PO/OD6.TAB.TELMISARTAN 40MG PO/OD7.TAB.MET-XL 25MG PO/OD8.TAB.ECOSPRIN GOLD

(75/75/20) PO/HS9.TAB.VYMADA 50MG PO/OD10.SYP CREMAFFIN PLUS 15ML

PO/STAT11.TAB.WYSOLONE 5MG PO/OD14.TAB.DIGOXIN 0.25 MG

PO/OD15.TAB.DABIGATRAN 110MG PO/BD16.SYP POTKLOR 15ML IN 100 ML WATER PO/TID

X5 DAYS17. TAB ZENFLOX - OZ PO/BD X 5 DAYS

Follow Up

REVIEW TO GM OPD IN 2 WEEKS

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/Attendant 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 : 3

75years/MALE

D. O. A :10/06/2024

D. O. D : 17/06/2024

Diagnosis

1)HEART FAILURE SECONDARY TO CAD/CAD AKINETIC

RCA,LCX HYPOKINETIC WITH REDUCED EF (32%)

2)ATRIAL FIBRILLATION

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

4)S/P B/L ORCHIODECTOMY SECONDARY TO CASTRATION RESISTENT

PROSTATE CARCINOMA 5 YEARS AGO

Case History and Clinical Findings

CHIEF COMPLAINTS:

SHORTNESS OF BREATH SINCE 1 WEEK

CHEST PAIN SINCE 1 WEEK

HISTORY OF PRESENT ILLNESS:

PATIENT WAS APPARENTLY AASYMPTOMATIC 1 WEEK BACK THEN HE DEVELOPED

DIFFICULTY IN BREATHEING SINCE 1 WEEK ASSOCIATEWD WITH ORTHOPNEA PND

SWEATING GIDDINESS .

PATIENT COMPLAINTS OF CHEST TIGHTNESS CHEST PAIN

PATIENT HAS NO H/O INVOLUNTARY MOVEMENTS

NO H/O ABDOMINAL PAIN

H/O NOCTURIA 5-6 TIMES AT NIGHT

PAST HISTORY:

K/C/O DM SINCE 3 MONTHS

K/C/F HTN SINCE 5 YEARS

PERSONAL HISTORY :

DIET - MIED

APPETITE - NORMAL

SLEEP - ADEQUATE

BOWEL& BLADDER MOVEMENTS - REGULAR AND NOCTURIA

ADDICTIONS - NIL

GENERAL PHYSICAL EXAMINATION :

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

PLACE .

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

VITALS :

BP ; 140/70MM HG

PR : 84 BPM

RR : 20CPM

TEMP ; 98F

SPO2 : 94 @ RA

GEBS- 137 MG/ DL

SYSTEMIC EXAMINATION :

CNS :NFND

REFLEXES

 B T S K A

 R +2 +2 + 1 +2 +1

 L +2 +2 +1 +2 +1

CVS :

S1, S2 HEARD , NO MURMURS

RS :

BAE + , NVBS

ADVENTITIOUS SOUNDS : CREPTS PRESENT

P/A :

SOFT , NON TENDER

COURSE IN THE HOSPITAL :

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

.CHEST PAIN SINCE 1 WEEK .ALL NECESSARY INVESTIGATIONS WERE SENT .PATIENT WAS

DIAGNOSED TO1)HEART FAILURE SECONDARY TO CAD/CAD AKINETIC ,RCA,LCX

HYPOKINETIC WITH REDUCED EF (32%) 2)ARTERIAL FIBRILLATION 3)K/C/O HTN SINCE 5

YEARS ; K/C/O DM2 SINCE 5 MONTHS 4)S/P B/L ORCHIODECTOMY SECONDARY TO

CASTRATION RESISTENT PROSTATE CARCINOMA 5 YEARS AGO. K/C/O DM SINCE 3

MONTHS .PATIENT WAS TREATED CONSERVATIVELY WITH

TAB.ECOSPRIN,TAB.DABIGATRAN,TAB.DIGOXIN,TAB.VYMADA,TAB.GLIMI-M1,SYP

POTKLOR,SYP.CREMAFFIN PLUS AND INJ AUGMENTIN AND INJ.METROGYL AND TAB METXL AND ACCORDINGLY .PATIENT IS BEING DISCHARGED IN A HEMODYNAMICALLY STABLE

CONDITION .

Investigation

Name Value Range

Name Value RangePOST LUNCH BLOOD SUGAR 10-06-2024 10:46:AM 138 mg/dl 140-0 mg/dl

RFT 10-06-2024 10:46:AMUREA 24 mg/dl 50-17 mg/dlCREATININE 0.8 mg/dl 1.3-0.8 mg/dlURIC

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

2.5 mg/dlSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.4 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

99 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 10-06-2024 10:46:AMTotal Bilurubin 2.90

mg/dl 1-0 mg/dlDirect Bilurubin 0.58 mg/dl 0.2-0.0 mg/dlSGOT(AST) 38 IU/L 35-0 IU/LSGPT(ALT) 35

IU/L 45-0 IU/LALKALINE PHOSPHATASE 103 IU/L 119-56 IU/LTOTAL PROTEINS 6.4 gm/dl 8.3-6.4

gm/dlALBUMIN 4.1 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.82

COMPLETE URINE EXAMINATION (CUE) 10-06-2024 10:46:AMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE

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

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilHBsAg-RAPID 10-06-

2024 10:46:AM Negative

Anti HCV Antibodies - RAPID 10-06-2024 10:46:AM Non ReactiveSERUM ELECTROLYTES (Na, K,

C l) 11-06-2024 05:21:AMSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.3 mmol/L 5.1-3.5

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

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

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

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

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

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

mmol/L 98-107 mmol/L

Treatment Given(Enter only Generic Name)

1.FLUID RESTRICTION <1.5L/DAY

2.SALT RESTRICTION <2.5 GM/DL

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

4.INJ.LASIX 40MG IV/OD

5.INJ.HAI S/C TID

6.TAB.TELMISARTAN 40MG PO/OD

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

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

9.TAB.ABIRATERONE 500MG PO/OD

10.TAB.VYMADA 50MG PO/OD

11.SYP CREMAFFIN PLUS 15ML PO/STAT

12.TAB.WYSOLONE 5MG PO/OD

15.TAB.DIGOXIN 0.25 MG PO/OD

16.TAB.DABIGATRAN 110MG PO/BD

17.TAB.GLIMI -M1 PO/BD

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

19. ZENFLOX - OZ PO/BD

Advice at Discharge

1.FLUID RESTRICTION <1.5L/DAY2.SALT RESTRICTION <2.5 GM/DL3.TAB . GLIMI M1

PO/OD6.TAB.TELMISARTAN 40MG PO/OD7.TAB.MET-XL 25MG PO/OD8.TAB.ECOSPRIN GOLD

(75/75/20) PO/HS9.TAB.VYMADA 50MG PO/OD10.SYP CREMAFFIN PLUS 15ML

PO/STAT11.TAB.WYSOLONE 5MG PO/OD14.TAB.DIGOXIN 0.25 MG

PO/OD15.TAB.DABIGATRAN 110MG PO/BD16.SYP POTKLOR 15ML IN 100 ML WATER PO/TID

X5 DAYS17. TAB ZENFLOX - OZ PO/BD X 5 DAYS

Follow Up

REVIEW TO GM OPD IN 2 WEEKS

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 - 4

71years/FEMALE

D. O. A : 23/06/2024

D. O. D : 24/04/2024

Diagnosis

ATRIAL FIBRILLATION

K/C/O HTN SINCE 20 YEARS

K/C/O CERVIVAL SPONDYLOSIS SINCE 3 YEARS

K/C/O CAD S/P PTCA 3 YEARS AGO

K/C/O HYPOTHYROIDISM SINCE 2 YEARS

Case History and Clinical Findings

C/O PALPITATIONS,GIDDINESS SINCE 1 HR

C/O BURNING MICTURITION SINCE 2 DAYS

C/O PEDAL EDEMA SINCE 3 DAYS

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC SINCE 1 HR THEN SHE DEVELOPED

PALPITATIONS NOT ASSOCIATED WITH CHEST PAIN,SOB

C/O GIDDINESS SINCE 1 HR,INSIDIOUS ONSET, NOT ASSOCIATED WITH POSTURAL

VARIATION.

TINNITUS,GIDDINESS ASSOCIATED WITH NECK ROTATION

NO C/O EAR ACHE,EAR DISCHARGE

C/O BURNING MICTURITION SINCE 2 DAYS NOT ASSOCIATED WITH FEVER WITH CHILLS,

ASSOCIATED WITH LOWER ABDOMEINAL PAIN

C/O PEDAL EDEMA SINCE 3 DAYS,INSIDIOUS ONSET,GRADUALLY PROGRESSIVE FROM

ANKLE TO BELOW KNEE

NO C/O NAUSEA,VOMITING,LOOSE STOOLS,FEVER,COUGH,COLD

PAST HISTORY: K/C/O HTN SINCE 20 YEARS ON T.TELMA 40 MG PO/OD

K/C/O AFIB SINCE 3 YEARS AND ON T.MET-XL 50 MG PO/OD

K/C/O S/P PTCAN 3 YEARS AGO AND ON T.CLOPITAB PO/HS

K/C/O HYPOTHYROIDISM SINCE 2 YEARS ON T.THYRONORM 25 MCG PO/OD

K/C/O CERVICAL SPONDYLOSIS SINCE 5 YEARS

N/K/C/O DM CVA TB ASTHMA EPILEPSY

PERSONAL HISTORY: HEAD NURSE BY OCCUPATION,NORMA APETITE,BOWEL AND

BLADDER REGULAR,NO ADDICTIONS

GENERAL EXAMINATION: NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY

TEMP-AFEBRILE

PR-126 BPM

RR-20 CPM

SPO2-98%@RA

GRBS-176 MG/DL

SYSTEMIC EXAMINATION:

CVS:S1S2+

RS:BAE+,NVBS+

CNS:NFND

P/A: SOFT NON TENDER

OPHTHALMOLOGY REFERRAL WAS DONE ON 23/6/24 I/V/O RAISED ICP CHANGES AND

HYPERTENSIVE RETINOPATHY CHANGES

DIAGNOSIS : B/E GRADE 3 HYPERTENSIVE RETINOPATHY

ADVICE : B/E E/D NEPAFENAC TID

Investigation

HEMOGRAM 24/6/24

HB-9.5

TLC-7800

N/L/E/M/B-70/23/1/6/0

PCV-29.1

RBC-3.92

PLT-1.72

RFT

UREA-33

CREATININE-1.4

URIC ACID-5.4

SODIUM-135

POTASSIUM-3.9

CHLORIDE-103

CALCIUM-9.7

CUEALB-NIL

SUGARS-NIL

RBC-NIL

PUS CELLS- 2-3

EPITHELIAL CELLS- 2-3

RBS-121 MG/DL

PT-16 SEC

INR-1.11

APTT- 33 SEC

COURSE IN THE HOSPITAL: PATIENT WAS ADMITTED I/V/O PALPITATIONS,GIDDINESS SINCE

1 HR,C/O BURNING MICTURITION SINCE 2 DAYS,C/O PEDAL EDEMA SINCE 3 DAYS AND WAS

INVESTIGATED ON FURTHER EVALUATION AND WAS DIAGNOSED WITH ATRIAL

FIBRILLATION WITH FVR, K/C/O CERVIVAL SPONDYLOSIS SINCE 3 YEARS, K/C/O CAD S/P

PTCA 3 YEARS AGO, K/C/O HYPOTHYROIDISM SINCE 2 YEARS, K/C/O HTN SINCE 2 YEARS,

?HEART FAILURE

PATIENT WAS MANAGED CONSERVATIVELY WITH

ANTIHYPERTENSIVE,DIURETIC,ANTACID,THYROID SUPPLEMENTATION

PATIENT IS STABLE AT THE TIME OF DISCHARGE

Treatment Given(Enter only Generic Name)

INJ PAN 40 MG IV/STAT

INJ LASIX 20 MG IV/STAT

T.TELMA 40 MG PO/STAT

T.MET XL 25 MG PO/STAT

T.VERTIN 8 MG PO/STAT

T.ECOSPIRIN GOLD 75/75/10 PO/HS

INJ.MET XL 2 MG IV/STAT

 SYP.CITRALKA PO/TID 10 ML IN 200 ML WATER

T.THYRONORM 25 MCG

Advice at Discharge

TAB.PAN 40 MG PO/OD X 7 DAYS

TAB.THYRONORM 20 MCG PO/OD TO CONTINUE

TAB.VERTIN 16MG PO/SOS

TAB.MET XL 50 MG PO/OD TO CONTINUE

SYP.CITRALKA 15 ML PO/TID 15 ML IN 1 GLASS OF WATER X 5 DAYS

TAB.ECOSPIRIN GOLD 75/75/10 PO/HS 0-0-1 TO CONTINUE

TAB.LASIX 40 MG PO/BD 8AM-0-4PM X 5 DAYS

TAB.TELMA 40 PO/OD 0-0-1 TO CONTINUE

Follow Up

REVIEW TO GM OPD AFTER 1 WEEK OR INFORM 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 : 5

81years/MALE

D. O. A : 24/07/2024

D. O. D : 24/07/2024

Diagnosis

ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE

ACUTE ISCHEMIC STROKE (LEFT HEMIPARESIS)

GTCS SECONDARY TO ACUTE ISCHEMIC STROKE

ACUTE KIDNEY INJURY ON CKD

COPD WITH COR PULMONALE

Case History and Clinical Findings

PATIENT CAME WITH CHIEF COMPLAINTS OF BREATHLESSNESS SINCE 1 DAY

 DECREASED URINE OUTPUT SINCE YESTERDAY AFTERNOON

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 1 DAY BACK, THEN HE DEVELOPED

SHORTNESS OF BREATH PROGRESSED FROM GRADE I TO GRADE III, INSIDIOUS IN ONSET

GRADUALLY PROGRESIVE IN NATURE WITH NO AGGREVATING AND RELIEVING FACTORS

C/O DECREASED URINE OUTPUT SINCE YESTERDAY NO C/O DRIBBLING OF

URINE,BURNING MICTURITION,HESITENCY,URGENCY

H/O HIGH GRADE FEVER 1 DAY AGO ASSOCIATED WITH CHILLS AND RIGORS ;

INTERMITTENT TYPE ; NO AGGRAVATING AND RELIEVING FACTORS

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

NO H/O COUGH,COLD

NO H/O PAIN ABDOMEN, LOOSE STOOLS, CONSTIPATION

PAST HISTORY :

N/K/C/O HTN, DM, TB, THYROID, CVA, CAD, EPILEPSY

HABITS - ALCOHOL - OCCASIONAL SINCE 60 YEARS

20 BIDIS PER DAY SINCE 60 YEARS

AT TIME OF ADMISSION :

TEMP:AFEBRILE

BP: 170/100 MM/HG

PR: 89 BPM

RR: 24 CPM

SPO2: 96% @ 10 LIT O2

GRBS : 137 MG/DL

PALLOR +

NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, OEDEMA

CVS : S1S2 +VE

RS: BAE+VE, NVBS

P/A - SOFT AND NON TENDER ,BS +VE

CNS :

GCS - E4V5M6

REFLEXES:- RT LT

BICEPS :- +2 +2

TRICEPS :- +1 +1

KNEES :- +2 +2

ANKLE :- +1 +1

SUPINATOR:- +1 +1

PLANTR - EXTENSION EXTENSION

Investigation

HAEMOGRAM 24/07/2024

HB- 13.2GM/DL

TLC- 40,400 CELLS/CUMM

N/L/E/M/B: 87/09/00/04/00

PCV: 35.0 VOL%

MCV: 80.3 FL

MCH: 30.3 PG

MCHC: 37.7 %

RBC COUNT: 4.36 M/ CU MM

PLT COUNT: 1.50 LAKHS

P/S- ncnc anemia with leukemoid reaction

ABG 24-07-2024 (2:15 PM)

PH 7.19

PCO2 13.4 MMHG

PO2 118 MMHG

HCO3 4.9 MMOL/L

St.HCO 8.9 MMOL/L

BEB -22.3 MMOL/L

BEecf -22.2 MMOL/L

TCO2 10.4 VOL

O2 Sat 96.6 %

O2 Count 17.4 VOL%

ABG 24-07-2024 (3:55 PM)

PH 7.14

PCO2 13.4 MMHG

PO2 160 MMHG

HCO3 4.4 MMOL/L

St.HCO 7.9 MMOL/L

BEB -23.5 MMOL/L

BEecf -23.3 MMOL/L

TCO2 9.7 VOL

O2 Sat 97.3 %

O2 Count 14.6 VOL%

ABG 24-07-2024 (7:35 PM)

PH 7.17

PCO2 11.5 MMHG

PO2 165 MMHG

HCO3 4.1 MMOL/L

St.HCO 8.1 MMOL/L

BEB -23.5 MMOL/L

BEecf -23.4 MMOL/L

TCO2 8.9 VOL

O2 Sat 97.8 %

O2 Count 16.1 VOL%

RFT 24-07-2024 UREA 128 mg/dl 42-12 mg/dlCREATININE 5.2 mg/dl 1.1-0.6 mg/dlURIC ACID 5.6

mmol/L 6-2.6 mmol/LCALCIUM 10.1 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 6.4 mg/dl 4.5-2.5

mg/dlSODIUM 137 mmol/L 145-136mmol/LPOTASSIUM 3.9 mmol/L. 5.1-3.5mmol/L.CHLORIDE 106

mmol/L 98-107mmol/L

Anti HCV Antibodies - RAPID 24-07-2024 - Non Reactive

HBsAg-RAPID 24-07-2024 - Negative

HIV 1/2- RAPID 24-07-2024 - NON- REACTIVE

RBS - 137 MG/DL

BLOOD LACTATE - 19.0 MG/DL

APTT - 36 SEC

PT - 18SEC

INR - 1.33

USG ABDOMEN (24/07/24)

IMPRESSION :-

POLYCYSTIC MORPHOLOGY OF BILATERAL KIDNEYS

2D ECHO WAS DONE ON 24/07/2024

TACHYCARDIC DURING STUDY

RWMA + , ANTERIOR WALL, LATERAL WALL HYPOKINESIA

MILD MR + ( MR TET ARAE 2.82 CM)

MILD TO MODERATE AR+ ( AR-PHT-636M/SEC)

MODERATE TO SEVERE TR+ ; MILD PAH (RVSP=38+10=48 MMHG)

EF=52 FAIR LV SYSTOLIC FUNCTION

MAC+;SCLEROTIC AV;NO AS/MS

IAS- INTACT/ANEURYSM

DILATED R.A/R.V/MPA/IVC

MILD TO MODERATE PR+ (MPA SIZE 2.65 CMS)

DIASTOLIC DYSFUNCTION +

MINIMAL PE + ; NO LV CLOT

IVC SIZE (1.54 CMS) MILD DILATED COLLAPSING

Treatment Given(Enter only Generic Name)

1. RYLES FEEDS 100 ML MILK 4TH HOURLY

 100 ML WATER 2ND HOURLY

2. IV FLUIDS @ URINE OUTPUT + 30 ML/HR

3. INJ. PIPTAZ 4.5 GM F/B 2.25 GM/IV/TID

4. INJ. PANTOP 40 MG/IV/OD

5. INJ. METROGYL 500 MG/IV/TID

6. INJ LEVIPIL 500 MG/IV/BD

7. INJ. LORAZEPAM 2MG/IV/SOS

8. INJ OPTINEURON IN 100ML/NS/IV/OD

9. INJ. THIAMINE 100 MG IV/BD

Follow Up

DEATH SUMMARY :-

80 YEAR OLD MALE RESIDENT OF KOTAMARTHY, FARMER BY OCCUPATION CAME TO

CASUALTY WITH C/O BREATHLESSNESS SINCE 2 DAYS, DECREASED URINE OUTPUT SINCE

YESTERDAY,ON ADMISSION VITALS TEMP-AFEBRILE, PR-89BPM, RR-36CPM, BP-

170/100MMHG, SPO2 - 70% ON RA, 96% WITH 10 LIT O2, ABG SHOWS PH-7.19, HCO3- 4.9,

PO2- 118, PCO2- 13.5, ECG SHOWED AF WITH FVR, PATIENT DEVELOPED SEIZURE LIKE

ACTIVITY IN CASUALTY WITH WITH WEAKNESS OF LEFT UPPER LIMB AND LOWER LIMB,

PATIENT WAS GIVEN INJ. LORAZEPAM 2CC/IV/STAT, INJ. AMIODARONE 150MG/IV/STAT ,F/B

150MG/IV/STAT AFTER THAT INFUSION STARTED, NAHCO3 100MEQ CORRECTION WAS

GIVEN, 2D ECHO WAS DONE WHICH SHOWED AF WITH RWMA (ANT, LAT WALL

HYPOKINESIA) [EF= 55%] FAIR LV, DILATED RA/RV/MPA/IVC MINIMAL PE. CT- BRAIN WAS

DONE, NO ABNORMALITY WAS DETECTED AT AROUND 6PM AS BP WAS NOT RECORDABLE

IONOTROPIC SUPPORT WAS GIVEN AT 7:30 PM I/V/O FALL IN SATURATION AND POOR GCS.

PATIENT WAS INTUBATED AND CONNECTED TO MECHANICAL VENTILATOR. AT 10PM

PATIENT CENTRAL PULSES WERE ABSENT AND THERE WAS FALL IN SATURATIONS, CPR

WAS INITIATED ACCORDING TO LATEST ACLS GUIDE LINES, 8 CYCLES WERE DONE.

INSPITE OF ABOVE ALL RESUSCITATION EFFORTS PATIENT WAS DECLARED DEAD ON

24/7/24 AT 10:28 PM WITH ECG SHOWING FLAT LINES

IMMEDIATE CAUSE :- ACUTE ISCHEMIC STROKE WITH GENERALISED TONIC CLONIC

SEIZURES

 ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE

ANTECEDENT CAUSE :- AKI ON CKD

 COPD WITH COR PULMONALE

 CAD-OLD ANTERIOR WALL MI

Death Date

Date: 24/07/2024

CASE NO : 6

76years/MALE

D. O. A : 09/08/2024

D. O. D : 09/08/2024

Diagnosis

TYPE 2 RESPIRATORY FAILURE

SEPSIS WITH MULTIPLE ORGAN DYSFUNCTION SYNDROME

BILATERAL LOWERLIMB CELLULITIS

ATRIAL FIBRILLATION WITH CONTROLLED VENTRICULAR RATE

KNOWN CASE OF HYPERTENSION

KNOWN CASE OF CEREBRO VASCULAR ACCIDENT

Case History and Clinical Findings

PATIENT CAME WITH C/O ALTERED SENSORIUM SINCE 2 DAYS

C/O FEVER SINCE 4 DAYS

C/O BILATERAL LOWER LIMB SWELLING SINCE 4 DAYS

HOPI:PATIENT WAS APPARENTLY ASYMPTOMATIC TILL 4 DAYS AGO THEN HE DEVELOPED

FEVER (HIGH GRADE ASSOCIATED WITH CHILLS) AND BILATERAL LOWER LIMB PITTING

TYPE OF EDEMA EHICH HAS LOCAL RISE OF TEMPERATURE ,TENDERNESS, NOT

ASSOCIATED WITH VOMITINGS,LOOSE STOOLS,PAIN ABDOMEN,BURNING MICTURITION,

COUGH,COLD,DECREASED URINE OUTPUT.C/O ALTERED SENSORIUM SINCE 2 DAYS NOT

ASOCIATED WITH LOSS OF CONCIOUSNESS,INVOLENTARY MOVEMENTS

PAST HISTORY

K/C/O HYPERTENSION SINCE 2 YEARS

H/O CEREBRO VASCULAR ACCIDENT 5 YEARS AGO (?H/O SYNCOPE AND FALL ONE

EPISODE-CT LESION SHOWED CHRONIC INFARCTS)

NOT K/C/O CAD,DM-II,THYROID DISORDERS,EPILEPSY

PERSONAL HISTORY:

DIET MIXED

APPETITE NORMAL

NORMAL BOWEL AND BLADDER MOVEMENTS

NO ADDICTIONS

GENERAL EXAMINATION:

PATIENT IS STUPOROUS, INCOHORENT (E2V2M5)

NO PALLOR, CTERUS, CYANOSIS, CLUBBING,LYMPHEDENOPATHY

PEDAL EDEMA PRESENT

BP:80/60

PR:108(IRREGULAR)

SPO2:88@RA

RR:24

SYSTEMIC EXAMINATION:

RS: NVBS+, BILATERAL BASAL CREPITUS PRESENT

CVS: S1 S2 HEARD, NO MURMURS

CNS :NFND

Investigation

ABG PH 7.17PCO2 63.0PO2 47.3HCO3 22.3St.HCO3 18.0BEB -7.3BEecf -5.0TCO2 46.4O2 Sat

71.2O2 Count 15.2

RFT

UREA 85 mg/dl 42-12 mg/dlCREATININE 3.4mg/dl 1.1-0.6 mg/dlURIC ACID 4.5 mmol/L 6-2.6

mmol/LCALCIUM 10.1 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 9.1mg/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 106 mmol/L 98-107

mmol/L

LIVER FUNCTION TEST (LFT) Total Bilurubin 0.75mg/dl 1-0 mg/dlDirect Bilurubin 0.19 mg/dl 0.2-0.0

mg/dlSGOT(AST) 125 IU/L 31-0 IU/LSGPT(ALT) 45 IU/L 34-0 IU/LALKALINE PHOSPHATASE 118

IU/L 98-42 IU/LTOTAL PROTEINS 5.6 gm/dl 8.3-6.4 gm/dlALBUMIN 3.2gm/dl 5.2-3.5 gm/dlA/G

RATIO 1.34

HBsAg-RAPID Negative

Anti HCV Antibodies - RAPID Non Reactive

HEMOGRAM

HEMOGLOBIN - 15.6 GM/DL

TOTAL COUNT - 8300 CELLS/CUMM

N/L/E/M/B-75/20/00/05/00

PCV -46.5

MCV-100.4 FL

MCH-33.7PG

MCHC -33.5

RBC COUNT -4.63 MILIONS/CUMM

PLATELET COUNT-80000 LAKHS/CUMM

SMEAR NORMOCYTIC NORMOCHROMIC WITH THROMBOCYTOPENIA

CRP- POSITIVE

ESR-40

BLOOD LACTATE-7.0 MG/DL

Treatment Given(Enter only Generic Name)

1.IVF- 10 NS IV/STAT

2.INJ NORADRENALINE (0.16MG/ML) @ 5ML/HR DECREASED /INCREASED TO MAINTAIN

MEAN ARTERIAL PRESSURE GREATER THAN 65MMHG

3.INJ PIPTAZ 4.5GM TV/STAT------2.25GM TV/TID

4.INJ ATRACURUM(2 AMP IN 45 ML NS) @ 5ML/HR

5.INJ MIDAZOLAM 30ML IN 20 ML NS @ 5ML/HR

6. INJ PAN 40MG IV OD BBF

7. STRICT I/O CHARTING

8.HOURLY VITALS MONITORING

DEATH SUMMARY-

A 74 YEAR OLD HYPERTENSIVE AND KNOWN CASE OF CEREBRO VASCULAR ACCIDENT

WAS BROUGHT TO CASUALITY IN AN UNRESPONSIVE STATE WITH GCS OF E1V2M3.H/O

FEVER AND BILATERAL LOWER LIMB SWELLING SINCE 4 DAYS FROM AN OUTSIDE

HOSPITAL WHERE HE WAS TREATED FOR SEPSIS WITH MULTIPLE ORGAN DYSFUNCTION

SYNDROME ,BILATERAL LOWER LIMB CELLULITIS, ACUTE KIDNEY INJURY WITH

THROMBOCYTOPENIA, ACUTE FEBRILE ILLNESS.PATIENT WAS ADMITTED AND TREATED IN

THE OUTSIDE HOSPITAL FOR 3 DAYS AND WAS DISCHARGED ON LAMA DUE TO PERSONAL

REASONS CAME HERE FOR FURTHER MANAGEMENT. VITALS AT PRESENTATION WERE

BP:80/60MMHG,PR: 108 BPM,RR:24CPM,SPO2:88% ON ROOM AIR

ABG SHOWED MIXED RESPIRATORY ACIDOSIS,METABOLIC ACIDOSIS WITH A PH : 7.17,

PCO2 : 63.0, PO2 : 47 , HCO3 : 18.0, ECG SHOWED IRREGULAR RHYTHM WITH ADSENT P

WAVES. PATIENT WAS INTUBATED I/V/O TYPE II RESPIRATORY FAILURE AND LOW GCS

(E1V2M3) AND WAS KEPT ON MECHANICAL VENTILATOR WITH FOLLOWING SETTINGS

ACMV-VC MODE , FiO2 70 %, PEEP : 5 CM H20 , VT : 420 ML , RR 20 CPM.

IN VIEW OF HYPOTESION TRIPLE LUMEN CATHETER WAS INSERTED AND INOTROPES

WERE STARTED (INJ NOR ADRENALINE).

AT AROUND 7:55PM PATIENT DEVELOPED BRADYCARDIA CENTRAL AND PERIPHERAL

PULSES WERE NOT FELT . CPR WAS INITIATED ACCORDING TO LATEST ACLS GUIDLINES

AND CONTINUED FOR 30 MINS.

INSPITE OF ALL RESUSCITATORY EFFORTS, PATIENT COULDNOT BE REVIVED AND

DECLARED DEAD ON 9/8/24 AT 8:31PM AFTER CONFIRMING WITH ECG FLAT LINE.

IMMEDIATE CAUSE OF DEATH -

1.TYPE II RESPIRATORY FAILURE 3.SEPSIS WITH MULTIPLE ORGAN DYSFUNCTION

SYNDROME

ANTECEDENT CAUSE-

1.ATRIAL FIBRILLATION WITH CONTROLLED VENTRICULAR RATE

2.BILATERAL LOWER LIMB CELLULITIS

3.KNOWN CASE OF HYPERTENSION 4.KNOWN CASE OF CEREBRO VASCULAR ACCIDENT

Death Date

Date:9/8/24

CASE NO : 7

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 : 8

61 years/MALE

D. O. A : 07/02/2024

D. O. D : 15/02/2024

Diagnosis

PERSISTENT ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE SECONDARY TO HFrEF

HEART FAILURE WITH REDUCED EJECTION FRACTION [EF-37%] SECONDARY TO

CORONARY ARTERY DISEASE

ISCHAEMIC CARDIOMYOPATHY

Case History and Clinical Findings

C/O DECREASED URINE OUTPUT SINCE 2 MONTHS

C/O PEDAL EDEMA SINCE 10 DAYS

C/O SOB SINCE 10 DAYS

C/O DECREASED URINE OUTPUT SINCE 2 MONTHS

NOT ASSOCIATED WITH FREQUENCY, URGENCY

C/O SOB SINCE 10 DAYS GRADE III ORTHOPNEA +

NO CHEST PAIN, PALPITATIONS + SINCE 10 DAYS

C/O PEDAL EDEMA SINCE 10 DAYS PITTING TYPE

NO H/O FEVER,COLD, COUGH

PAST HISTORY

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

H/O HERNIOPLASTY 2 MONTHS BACK.

PERSONAL HISTORY:

OCCUPATION-DAILY WAGE LABOURER

DIET- VEGETARIAN

APPETITE-DECREASED SINCE 10 DAYS

SLEEP-ADEQUATE

BOWEL MOVEMENTS-REGULAR

ADDICTIONS- ALCOHOLIC CONSUMES 90ML OCCASIONALLY STOPPED SINCE 2 MONTHS

CHUTTA STOPPED SINCE 3 MONTHS

FAMILY HISTORY:NO SIGNIFICANT FAMILY HISORY

GENERAL PHYSICAL EXAMINATION:

PT IS C/C/C

PALLOR-PRESENT

PEDAL EDEMA - GRADE III SINCE 10 DAYS

NOICTERUS, CYANOSIS,CLUBBING,LYMPHADENOPATHY

TEMP- 98.6 F

PR-130BPM

RR-20/MIN

BP-90/60MMHG

SPO2-98%@RA

GRBS- 100MG/DL

SYSTEMIC EXAMINATION:

CVS-S1S2 HEARD

R/S-BAE+,NVBS HEARD

CNS- NFND

P/A - SOFT, NON TENDER, BOWEL SOUNDS +

Investigation

LIVER FUNCTION TEST (LFT)

Total Bilurubin 1.06 mg/dl

Direct Bilurubin 0.20 mg/dl

SGOT(AST) 28 IU/L

SGPT(ALT) 24 IU/L

ALKALINE PHOSPHATASE 156 IU/L

TOTAL PROTEINS 6.8 gm/dl

ALBUMIN 3.8 gm/dl

A/G RATIO 1.26

RFT

UREA 26 mg/dl

CREATININE 1.0 mg/dl

URIC ACID 3.9 mg/dl

lCALCIUM 9.4 mg/dl

PHOSPHOROUS 4.1 mg/dl

SODIUM 130 mEq/L

POTASSIUM 3.6 mEq/L

CHLORIDE 98 mEq/L

POST LUNCH BLOOD SUGAR 126 mg/dl

BLOOD UREA 24 mg/dl SERUM CREATININE 0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM

SODIUM 129 mEq/L

POTASSIUM 3.4 mEq/L

CHLORIDE 87 mEq/L

CALCIUM IONIZED 1.14 mmol/L

COMPLETE URINE EXAMINATION (CUE)

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN +

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 4-5

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

HBsAg-RAPID Negative

Anti HCV Antibodies - RAPID Non Reactive

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM

SODIUM 130 mEq/L

POTASSIUM 3.5 mEq/L

CHLORIDE 94 mEq/L

CALCIUM IONIZED 1.06 mmol/L

T3, T4, TSH 0

T3 0.82 ng/ml

T4 15.27 micro g/dl

TSH 8.42 micro Iu/ml

BLOOD UREA 25 mg/dl

SERUM CREATININE 0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM

SODIUM 135 mEq/L

POTASSIUM 3.3 mEq/L

CHLORIDE 98 mEq/L

CALCIUM IONIZED 1.06 mmol/L

BLOOD UREA 24 mg/dl

SERUM CREATININE 0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM

SODIUM 137 mEq/L

POTASSIUM 3.0 mEq/L

CHLORIDE 99 mEq/L

CALCIUM IONIZED 1.21 mmol/L

2D ECHO

MITRAL VALVE - MAC + ,THICKENED

TRICUSPID VALVE -CALCIFIED

PULMONARY VALVE NORMAL

AORTIC VALVE - SCLEROTIC

RIGHT ATRIUM,LEFT ATRIUM - GROSS DILATED

RIGHT VENTRICLE -DILATED

LEFT VENTRICLE -RWMA ,LAD AKINETIC,RCA AND LCX HYPOKINESIA

EF -37%

IVC SIZE - 2.02Cms,DILATED ,NON COLLAPSING

MR JT -8.32 Cm2

SEVERE MR ,SEVERE TR,MILD PAH

SEVERE LV DYSFUNCTION

NO DIASTOLIC DYSFUNCTION

USG ABDOMEN

B/L PLEURAL EFFUSION

GB WALL EDEMA

MODERATE ASCITES

MINIMAL PERICARDIAL EFFUSION

GRADE 1 FATTY LIVER

RIGHT KIDNEY -GRADE I RPD CHANGES

LEFT KIDNEY - RAISED ECHOGENECITY

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <1.5 L /DAY

SALT RESTRICTION <2GM/DAY

INJ. LASIX 20MG IV BD

INJ CLEXANE 40MG SC BD X 7 DAYS

TAB DIGOXIN 0.5MG STAT

TAB DIGOXIN 0.25MGPO OD 8AM-X-X

TAB WARFARIN 1MG OD X 1 DAY

TAB MET XL 25MG PO OD

TAB ECOSPIRIN 75MG PO HS

TAB CLOPIDOGREL 75MG PO HS

TAB ATORVASTATIN 40MG PO HS

TAB ALDACTONE 25MG OD

INJ KCL 2 AMP + INJ MGSO4 1AMP IN 500ML NS IV OVER 5 HOURS

Advice at Discharge

FLUID RESTRICTION <1.5 L /DAY

SALT RESTRICTION <2GM/DAY

TAB LASIX 20MG PO BD CONTINUE 8AM -X-4PM CONTINUE

TAB DIGOXIN 0.25MGPO OD 8AM-X-X CONTINUE

TAB WARFARIN 2MG OD CONTINUE X-2PM-X CONTINUE

TAB MET XL 25MG PO OD CONTINUE 1-X-X CONTINUE

TAB ECOSPIRIN 75MG PO HS CONTINUE X-X-8PM CONTINUE

TAB CLOPIDOGREL 75MG PO HS CONTINUE X-X-8PM CONTINUE

TAB ATORVASTATIN 40MG PO HS CONTINUE X-X-8PM CONTINUE

TAB ALDACTONE 25MG OD CONTINUE 1-X-X CONTINUE

Follow Up

REVIEW 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 : 9

60years/MALE

D. O. A : 27/01/2025

D. O. D : 31/01/2025

Diagnosis

ACS - CAD - IWMI

TYPE-2 RESPIRATORY FAILURE

ANOXIC ENCEPHALOPATHY

SEPTIC SHOCK WITH PRE RENAL AKI SECONDARY TO LEFT LOWER LIMB CELLULITIS

PAROXYSMAL AF WITH CVR

VT S/P DC SHOCK

K/C/O COPD

K/C/O T2DM.

Case History and Clinical Findings

PATIENT WAS BROUGHT TO CASUALTY IN UNRESPONSIVE AND GASPING STATE FROM

OUTSIDE HOSPITAL

C/O SWELLING OF LEFT LOWER LIMB WITH BLEBS OVER LEFT LEG SINCE 7 DAYS, WHICH

PROGRESSED FROM A LOCALISED TO DIFFUSE SWELLING A/W REDNESS AND BLEBS.

H/O HIGH GRADE FEVER WITH CHILLS

H/O SOB GRADE 2 TO 3

H/O VOMITINGS 4 DAYS AGO 4-5 EPISODES/ DAY WHICH SUBSIDED IN 2 DAYS

NO H/O CHEST PAIN, PALPITATION, SWEATING

NO H/O HEADACHE, GIDDINESS, DIPLOPIA

PATIENT WAS TAKEN TO OUTSIDE HOSPITAL WITH ABOVE COMPLAINTS WHERE HE WAS

SEDATED AS PATIENT WAS IRRITABLE AND AGGRESIVE, SINCE THEN HE WAS

UNRESPONSIVE.

PAST HISTORY:

K/C/O OF TYPE 2 DM SINCE 4YEARS USED MEDICATIONS FOR 1 MONTH

K/C/O COPD SINCE 4 YEARS

N/K/C/O OF CAD, CVA, SEIZURES, BRONCHIAL ASTHMA, TB.

PERSONAL HISTORY

DIET-MIXED

SLEEP-ADEQUATE

APPETITE-NORMAL

BOWEL MOVEMENTS-- REGULAR

MICTURITION- NORMAL

ADDICTIONS: ALOCHOL-REGULAR-90-180ML/DAY SINCE 40YEARS, BEEDI 2PACKS /DAY

SINCE 40YEARS.

GENERAL EXAMINATION

PT IS IN COMA, NO RESPONSIVE STATE

TEMP: AFEBRILE

PR: 48 BPM

SBP: 70MMHG(PALPATORY METHOD)

RR: 18CYCLES PER MIN

SPO2: 88% AT 6 LIT OF O2

GRBS: 70MG/DL

SYSTEMIC EXAMINATION:

CVS:S1 S2 HEARD , NO MURMURS

RS:BAE +, DYSPNEA +, B/L DIFFUSE COARSE CREPTS AND RHONCHI PRESENT

P/A:SOFT,NT, NO ORAGANOMEGALY

CNS: PATIENT IS IN COMATOSE STATEWITH UNRESPONSIVE STATE; GCS:(3/15) E1V1M1

SIGNS OF MENINGEAL IRRITATION: COULDN'T BE ELICITED

CRANIAL NERVES: COULDN'T BE ELICITED

SENSORY SYSTEM: COULDN'T BE ELICITED

MOTOR SYSTEM: COULDN'T BE ELICITED

REFLEXES: COULDN'T BE ELICITED

CEREBELLAR SIGNS: COULDN'T BE ELICITED

Investigation

ON 27/01/25:Blood Lactate:10.2mg/dlHBA1c: 6.7%RBS:209mg/dl.ABG:

27/01/25PH:6.83PCO2:154mmHgPO2:15.5mmHgHCO3:24.3mmol/LSt.HCO3:11.7mmol/LBEB:-

15.3mmol/LBEecf:-9.0mmol/LTCO2:60.8VOLO2 Sat:7.9%O2 Count:1.4vol %APTT TEST:33 SecPT:

17SECINR: 1.2BLEEDING TIME: 2MIN 30SECCLOTTING TIME: 5MIN 00SECCOMPLETE URINE

EXAMINATION (CUE) 27-01-2025 COLOUR Pale yellowAPPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR +BILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-

4EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS

DEPOSITS AbsentOTHERS NilURINE FOR KETONE BODIES: NEGATIVEHEMOGRAM: 27/01/25

HAEMOGLOBIN 8.3GM/DL

TOTAL COUNT 19,000 CELLS/CUMM

NEUTROPHILS 85%

LYMPHOCYTES 08%

EOSINOPHILS 01%

MONOCYTES 06%

BASOPHILS 00%

PCV 25.8 VOL%

MCV 84.4 FL

MCH 27.1 PG

MCHC 32.1%

RDW-CV 13.1%

RDW-SD 42.2FL

RBC COUNT 3.06 MILLIONS/CUMM

PLATELET COUNT 2.19 LAKHS/CUMM

SMEAR

RBC NORMOCYTIC NORMOCHROMIC

WBC INCREASED IN COUNT WITH NEUTROPHILA

PLATELETS ADEQUATE

HEMOPARASITES NOT SEEN

IMPRESSION NORMOCYTIC NORMOCHROMIC ANEMIA WITH NEUTROHILIC.

LEUKOCYTOSISLIVER FUNCTION TEST (LFT) 27-01-2025 Total Bilurubin 0.42 mg/dl Direct

Bilurubin 0.15 mg/dl SGOT(AST) 26 IU/LSGPT(ALT) 13IU/L ALKALINE PHOSPHATASE 719 IU/L

TOTAL PROTEINS 5.9 gm/dl ALBUMIN 3.58 gm/dl A/G RATIO 1.54RFT 27-01-2025UREA 81

mg/dlCREATININE 1.9 mg/dlURIC ACID 5.8 mmol/L CALCIUM 8.5 mg/dl PHOSPHOROUS 7.8 mg/dl

SODIUM 132 mmol/L POTASSIUM 4.5 mmol/L. CHLORIDE 104 mmol/LSEROLOGY:

NEGATIVE

LIVER FUNCTION TEST (LFT) 28-01-2025 Total Bilurubin 1.10 mg/dl Direct Bilurubin

0.25 mg/dl SGOT(AST) 116 IU/LSGPT(ALT) 275U/L ALKALINE PHOSPHATASE 196IU/L TOTAL

PROTEINS 4.4 gm/dl ALBUMIN 2.4 gm/dl A/G RATIO 0.83ABG:

28/01/25PH:6.99PCO2:73.9mmHgPO2:38.5mmHgHCO3:16.9mmol/LSt.HCO3:12.3mmol/LBEB:-

15.5mmol/LBEecf:-12.8mmol/LTCO2:39.1VOLO2 Sat:64.1%O2 Count:10.6vol %RFT 28-01-

2025UREA 85 mg/dlCREATININE 2.0 mg/dlURIC ACID 6.1 mmol/L CALCIUM 8.4mg/dl

PHOSPHOROUS 7.6 mg/dl SODIUM 135 mmol/L POTASSIUM 4.2 mmol/L. CHLORIDE

99mmol/LABG:

28/01/25PH:7.05PCO2:64mmHgPO2:176mmHgHCO3:16.9mmol/LSt.HCO3:13.7mmol/LBEB:-

14.3mmol/LBEecf:-11.9mmol/LTCO2:37.4VOLO2 Sat:98.6%O2 Count:17.9vol %HEMOGRAM:

28/01/25

HAEMOGLOBIN 13.6GM/DL

TOTAL COUNT 18,000 CELLS/CUMM

NEUTROPHILS 82%

LYMPHOCYTES 12%

EOSINOPHILS 00%

MONOCYTES 06%

BASOPHILS 00%

PCV 40.6 VOL%

MCV 89.6 FL

MCH 29.9 PG MCHC 33.4% RDW-CV 14.9.1% RDW-SD 48.9FLRBC COUNT 4.54

MILLIONS/CUMM PLATELET COUNT 62,000/CUMM

SMEAR:RBC NORMOCYTIC NORMOCHROMIC

WBC INCREASED IN COUNTS ON SMEAR WITH ABSOLUTE NEUTROPHILA

PLATELETS INADEQUATE

HEMOPARASITES NOT SEEN

IMPRESSION NORMOCYTIC NORMOCHROMIC ANEMIA WITH NEUTROHILIC LEUKOCYTOSIS

AND THROMBOCYTOPENIA.

ABG:

29/01/25PH:7.11PCO2:45.8mmHgPO2:44.1mmHgHCO3:13.9mmol/LSt.HCO3:12.6mmol/LBEB:-

15.3mmol/LBEecf:-13.8mmol/LTCO2:30.3VOLO2 Sat:71.4%O2 Count:13.1vol %RFT 29-01-

2025UREA 104 mg/dlCREATININE 2.9 mg/dlURIC ACID 6.8 mmol/L CALCIUM 7.1mg/dl

PHOSPHOROUS 7.58 mg/dl SODIUM 136 mmol/L POTASSIUM 3.9 mmol/L. CHLORIDE

99mmol/LHEMOGRAM: 29/01/25

HAEMOGLOBIN:12.1GM/DL

TOTAL COUNT 15,290 CELLS/CUMM

NEUTROPHILS 86%

LYMPHOCYTES 05%

EOSINOPHILS 01%

MONOCYTES 08%

BASOPHILS 00%

PCV 35.8 VOL%

MCV 88.6 FL

MCH 30.0 PG

MCHC 33.8%

RDW-CV 15.2%

RDW-SD 49.7FL

RBC COUNT 4.04 MILLIONS/CUMM

PLATELET COUNT 1 LAKH/CUMM

SMEAR

RBC NORMOCYTIC NORMOCHROMIC

WBC INCREASED IN COUNTS ON SMEAR WITH ABSOLUTE NEUTROPHILA

PLATELETS INADEQUATE

HEMOPARASITES NOT SEENIMPRESSION NORMOCYTIC NORMOCHROMIC ANEMIA WITH

NEUTROHILIC LEUKOCYTOSIS AND DECREASED LYMPHOCYTESRFT 29-01-2025UREA 116

mg/dlCREATININE 3.2 mg/dlURIC ACID 6.6 mmol/L CALCIUM 8.2mg/dl PHOSPHOROUS 8.7 mg/dl

SODIUM 135 mmol/L POTASSIUM 5.3 mmol/L. CHLORIDE 104mmol/LRFT 30-01-2025UREA 136

mg/dlCREATININE 3.5 mg/dlURIC ACID 7.0 mmol/L CALCIUM 8.0mg/dl PHOSPHOROUS 9.5 mg/dl

SODIUM 132 mmol/L POTASSIUM 5.6 mmol/L. CHLORIDE 102mmol/LHEMOGRAM: 30/01/25

HAEMOGLOBIN:11.5GM/DL

TOTAL COUNT 18,000 CELLS/CUMM

NEUTROPHILS 83%

LYMPHOCYTES 04%

EOSINOPHILS 01%

MONOCYTES 12%

BASOPHILS 00%

PCV 33.2 VOL%

MCV 89.1 FL

MCH 30.9 PG

MCHC 34.6%

RDW-CV 15.7%

RDW-SD 51.3FL

CASE NO : 10

65 years/MALE

D. O. A : 29/01/2025

D. O. D : 29/01/2025

Diagnosis

PAROXYSMAL ATRIAL FIBRILLATION

K/C/O DM, HTN

Case History and Clinical Findings

C/O CHEST PAIN SINCE 6PM.

HOPI: PATIENT WAS APPARENLTY ASYMPTOMATIC UNTIL 6PM TODAY, THEN HE

DEVELOPED CHEST PAIN WHICH WAS SUDDEN IN ONSET, LEFT SIDED PRICKING TYPE,

NON-RADIATING, A/W EXERTIONAL SOB AND GIDDINESS. NO H/O PALPITATIONS,

SWEATING, SYNCOPE. NO H/O COUGH, COLD, FEVER.

NO H/O PAIN ABDOMEN, LOOSE STOOLS, VOMITINGS. NO H/O JAW PAIN, SHOULDER PAIN.

H/O FATIGUE+. NO H/O PEDAL EDEMA, DECREASED URINE OUTPUT, FACIAL PUFFINESS

NO H/O ABDOMINAL DISTENSION

PAST HISTORY:-

K/C/O HTN SINCE 10 YEARS, ON T.AMLONG AT 5/50MG PO/OD

K/C/O TYPE II DM, ON T GLIMI-M2 PO/OD

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

GENERAL EXAMINATION:-

PATIENT IS C/C/C

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

TEMP: 98F

BP: 130/90MMHG

PR: 154BPM

RR: 20CPM

SPO2: 98% @RA

GRBS: 358MG/DL

APPETITE - NORMAL

BOWELS - REGULAR

MICTURITION - NORMAL

NO ALLERGIES

OCCASIONAL CONSUMPTION OF ALCOHOL, STOPPED 10 YEARS AGO

TOBACCO SMOKER(BEEDI), STOPPED 10 YEARS AGO

SYSTEMIC EXAMINATION:-

CVS: S1, S2+, NO MURMURS

RS: BAE+, NVBS HEARD

P/A: SOFT, NON-TENDER

CNS: NFND

Investigation

BLOOD UREA 29-01-2025 10:52:PM 52 mg/dl 50-17 mg/dl

SERUM CREATININE 29-01-2025 10:52:PM 2.1 mg/dl 1.3-0.8 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 29-01-2025 10:52:PMSODIUM 135 mmol/L 145-136

mmol/LPOTASSIUM 4.0 mmol/L 5.1-3.5 mmol/LCHLORIDE 104 mmol/L 98-107 mmol/L

APTT TEST 33 Sec 24-33 Sec

Prothrombin Time 17 Sec 10-16secINR 1.2

HEMOGRAM ON 29/1/2025:-

HAEMOGLOBIN 15.3 gm/dl 13.0 - 17.0 ColorimetricTOTAL COUNT 7,700 cells/cumm 4000 - 10000

ImpedenceNEUTROPHILS 62 % 40 - 80 Light MicroscopyLYMPHOCYTES 30 % 20 - 40 Light

MicroscopyEOSINOPHILS 02 % 01 - 06 Light MicroscopyMONOCYTES 06 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 42.8 vol % 40 - 50 CalculationM C V 90.8 fl

83 - 101 CalculationM C H 32.5 pg 27 - 32 CalculationM C H C 35.8 % 31.5 - 34.5 CalculationRDWCV 13.3 % 11.6 - 14.0 HistogramRDW-SD 47.8 fl 39.0-46.0 HistogramRBC COUNT 4.72

millions/cumm 4.5 - 5.5 ImpedencePLATELET COUNT 1.5 lakhs/cu.mm 1.5-4.1

ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light

MicroscopyPLATELETS Adeqaute Light MicroscopyHEMOPARASITES No hemoparasites seen Light

MicroscopyIMPRESSION Normocytic normochromic blood picture

Treatment Given(Enter only Generic Name)

INJ METOPROLOL 1CC IV/STAT

INJ AMIODARONE 150MG IN 100ML NS IV/STAT

T.GLIMI-M2 25MG PO/BD

T.MET-XL 25MG PO/BD

T.AMLODIPINE 5MG PO/OD

T.APLAXABAN 2.5MG PO/OD

MONITOR VITALS AND INFORM SOS

Advice at Discharge

PATIENT ATTENDERS HAVE BEEN EXPLAINED ABOUT PATIENT'S CONDITION, I.E

PAROXYSMAL ATRIAL FIBRILLATION SECONDARY TO ?HEART FAILURE, K/C/O HTN, DM. THE

RISKS AND COMPLICATIONS ASSOCIATED WITH IT LIKE EMBOLIC STROKE, HYPOTENSION,

HAVE BEEN EXPLAINED. THE NEED FOR FURTHER EVALUATION AND MANAGEMENT AND IN

HOSPITAL FOR OBSERVATION HAS BEEN EXPLAINED IN THEIR OWN UNDERSTANDABLE

LANGUAGE. BUT PATIENT AND HIS ATTENDERS ARE NOT WILLING FOR FURTHER

HOSPITAL STAY DUE TO PERSONAL REASONS. PATIENT IS CLINICALLY STABLE AND

HENCE IS BEING DISCHARGED AT REQUEST.

HOSPITAL STAFF, DOCTORS, NURSES AND MANAGEMENT ARE NOT RESPONSIBLE FOR

ANY UNTOWARD EVENTS AFTER LEAVING THE HOSPITAL.

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.

Discharge Date

Date:29/1/2025

CASE NO : 11

52years/MALE

D. O. A : 30/01/2025

D. O. D : 31/01/2025

Diagnosis

- REFRACTORY SHOCK ? CARDIOGENIC ? HEMORRHAGIC SECONDARY TO UPPER BLEED

-DECOMPENSATED CLD WITH PORTAL HYPERTENSION (ASCITES , OESOPHAGEAL

VARICES

-AF WITH FVR

-HFREF WITH SEVERE LV DYSFUNCTION SECONDARY TO CAD

-THROMBOCYTOPENIA WITH METABOLIC ACIDOSIS

Case History and Clinical Findings

PATIENT WAS BROUGHT WITH CHIEF COMPLAINTS OF SWELLING OF BOTH LOWER LIMBS

SINCE 1 WEEK , DIFFICULTY IN BREATHING SINCE 1 WEEK

HOPI:

PATIENT WAS APPARENTLY NORMAL 1 WEEK BACK THEN GRADUALLY DEVELOPED

SWELLING IN BOTH LOWERLIMBS (GRADE IV PITTING TYPE ) ANDDIFFICULTY IN

BREATHING GRADUALLY PROGRESSIVE FROM GRADE III-IV NYHA

PAST HISTORYN/K/C/O DM, HTN,TB,EPILEPSY,ASTHMA,CVA,CAD

PERSONAL HISTORY

DIET-MIXED

SLEEP-ADEQUATE

APPETITE- NORMAL

BOWEL AND BLADDER MOVEMENTS- REGULAR

ADDICTIONS : NONE

GENERAL EXAMINATION

PT IS C/C/C

PALLOR PRESENT

ICTERUS PRESENT

NO CYANOSIS ,CLUBBING ,LYMPHADENOPATHY

BILATERAL GRADE IV PEDAL EDEMA PRESENT

TEMP.AFEBRILE

BP:80/50 MMHG

PR :168BPM

RR:32CPM

SPO2 :94% @ROOM AIR

GRBS:43MG/DL .

SYSTEMIC EXAMINATION:

CVS:S1 S2 HEARD , JVP RAISED

 APEX SHIFTED TO DOWN AND OUT 6TH ICS LATERAL TO MCL LEFT

RS:BAE PRESENT,NVBS

 BASAL CREPTS +

CNS: NFND

P/A:DISTENDED

Investigation

HAEMOGLOBIN 10.8 gm/dlTOTAL COUNT 10700 cells/cummNEUTROPHILS 90

%LYMPHOCYTES 05 %EOSINOPHILS 00%MONOCYTES 05%BASOPHILS 00 %PCV 29.8 vol %M

C V 85.9 flM C H 30.6 pgM C H C 36.0 %RDW-CV 14.9 %RDW-SD 47.1 flRBC COUNT 3

millions/cummPLATELET COUNT 18000 lakhs/cu.mmSMEARRBC Normocytic normochromicWBC

With in normal limitsPLATELETS AdeqauteHEMOPARASITES No hemoparasites seenIMPRESSION

Normocytic normochromic bloodpicture

HBsAg-RAPID Negative

Anti HCV Antibodies - RAPID Non Reactive

HIV 1/2 Rapid Test Non Reactive

C-Reactive Protein Positive(4.8mg/dl)

.

.

.

Blood Lactate 6.3 mg/dl

LDH 334 IU/L.

APTT :35 SEC

PT :18 SEC

INR :1.33

ESR :20

RBS:80MG/DL

RFT UREA 82 mg/dl CREATININE 1.0 mg/dl URIC ACID 3.4 mmol/L CALCIUM 8.6 mg/dl

PHOSPHOROUS 2.7 mg/dl SODIUM 134 mmol/L POTASSIUM 3.8 mmol/L.CHLORIDE 98 mmol/L

LIVER FUNCTION TEST (LFT) Total Bilurubin 12.23 mg/dl Direct Bilurubin 8.44mg/dlSGOT(AST) 67

IU/L SGPT(ALT) 89 IU/L ALKALINE PHOSPHATASE 110 IU/L TOTAL PROTEINS 4.5 gm/dl

ALBUMIN 1.9 gm/dl A/G RATIO 0.74

PHOSPHORUS :2.7MG/DL

SERUM MAGNESIUM :1.8MG/DL

SERUM FOR OSMOLALITY :295.5 mOSM/KG

COMPLETE URINE EXAMINATION (CUE) COLOUR Pale yellowAPPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 0-

1EPITHELIAL CELLS 1-2RED BLOOD CELLS 1-2CRYSTALS NilCASTS NilAMORPHOUS

DEPOSITS AbsentOTHERS BILE SALTS PRESENT

2D ECHO

SHOWED GLOBAL HYPOKINESIA ,MODERATE MR ,SEVERE TR WITH PAH (PVSP =80 MMHG)

EF=22% WITH SEVERE LV DYSFUNCTION ,DIALATED CHAMBERS ,AND NON COLLAPSING

DIALATED IVC.

USG :

SUBOPTIMAL SCAN GASEOUS ABDOMEN :

FINDINGS :

 EVIDENCE OF FREE FLUID NOTED IN BILATERAL PLEURAL SPACE WITH UNDERLYING LUNG

COLLAPSE AND CONSOLIDATIONS

MODERATE TO GROSS FLUID IN PERIHEPATIC AND PERISPLENIC WITH SEPTATIONS .

MILD SURFACE NODULARITY6 OF LIVER WITH SLIGHTLY ALTERED ECHOTEXTURE .

IMPRESSION :

MODERATE TO GROSS ASCITES WITH SEPTATIONS

BILATERAL PLEURAL EFFUSIONS WITHUNDERLYING LUNG COLLAPSE AND

CONSOLIDATIONS

REACTIVE GALL BLADDER WLL EDEMA

MILD SURFACE NODULARITY6 OF LIVER WITH SLIGHTLY ALTERED ECHOTEXTURE . LIKELY

CHRONIC LIVER DISEASE CHANGES

Treatment Given(Enter only Generic Name)

IV FLUIDS NS @30 ML/HR

INJ.NORADRENALINE 2 AMP IN 46ML NS @5ML/HR

INJ.DOBUTAMINE 1 AMP IN 45 ML NS @3.6 ML/HR

INJ.VASOPRESSIN 2 AMP IN 38 ML NS @2.4 ML/HR

INJ.SODIUMBICARBONATE 100MEQ IN 200ML NS OVER 1HR

INJ.AMLODERONE 0.5 MG /KG/MIN OVER 18 HRS

INJ.TRANEXA 1GM IV /STAT

IV INFUSION 25% DEXTROSE @15ML/HR

INJ.THYMINE 200MG IN 100 ML NS IV/OD

TAB.CARDIVAS 3.125 MG RT/BD

TAB.RIBAROXABAN 10MG RT/BD

TAB.DAPAGLIFLOZIN 100MG RT/OD

STRICT I/O CHARTING

MONITER VITALS HOURLY

POSITION CHNAGE 2ND HOURLY

ET AND ORAL SUCTIONING 2ND HOURLY

DEATH SUMMARY

 THIS IS CASE OF 52 YEAR OLD MALE , RESIDENT OF AMMA NANNA ANADHASHRAMAM ,WAS

BROUGHT WITH CHIEF COMPLAINTS OF SWELLING OF BOTH LOWER LIMBS SINCE 1 WEEK ,

DIFFICULTY IN BREATHING OF GRADE III-IV NYHA SINCE 1 WEEK ,VITALS AT

PRESENTATION BP:80/50 MMHG ;PR :168BPM RR:32CPM ;SPO2 :94% @ROOMAIR

;GRBS:43MG/DL . IMJ.25%DEXTROSE WAS GIVEN . ECG SHOWED AF WITH FVR ,ABG

SHOWED METABOLIC ACIDOSIS . ALL THE APPROPRIATE INVESTIGATIONS WERE SENT .2D

ECHO SHOWED GLOBAL HYPOKINESIA ,MODERATE MR ,SEVERE TR WITH PAH (PVSP =80

MMHG) EF=22% WITH SEVERE LV DYSFUNCTION ,DIALATED CHAMBERS ,AND NON

COLLAPSING DIALATED IVC . INJ.AMIDIRONE 150 MG IV STAT WAS GIVEN FOLLOWED BY

INFUSION @33ML/HR . PATIENT WAS STARTED ON DUAL INOTROPIC SUPPORT .

HEMOGRAM SHOWED THROMBOCYTOPENIA (10000) .LFT'S WERE DERANGED WITH

TB:12.23 ; DB :8.4 ; SGOT:67 ; SGPT:89 ; ALP:110 ; ALBUMIN:1.9 . USG ABDOMEN SHOWED

MODERATE TO GROSS ASCITIES WITH SEPTATIONS ,BILATERAL PLEURAL EFFUSIONS

WITH UNDERLYING LUNG COLLAPSE AND CONSOLIDATIONS ,REACTIVE GALLBLADDER

WALL EDEMA , MILD SURFACE NODULARITY OF LIVER SUGGESTING CHRONIC LIVER

DISEASE CHANGES .AT AROUND 9:30 PM , PATIENT DEVELOPED RESPIRATORY DISTRESS

AND SENSORIUM WAS DETORIATED . INTUBATION WAS DONE AFTER ADEQUATE

SEDATION AND PARALYSIS AND CONNECTED TO MECHANICAL VENTILATORS IN ACMV-VC

MODE.AFTER INTUBATION ,PATIENT DEVELOPED BRADYCARDIA WITH ABSENT CENTRAL

PULSE , ONE CYCLE CPR WAS DONE AFTER WHICH ROSC WAS ACHIEVED ON 31/01/2025 AT

AROUND 1:45 AM , PATIENT DEVELOPED BRADYCARDIA WITH NON RECORDABLE BP AND

ABSENT CENTRAL PULSES , CPR WAS INITIATED AND CONTINUED FOR 30 MINUTES

.IJNSPITE OF ALL THE ABOVE RESUSITATION EFFORTS , PATIENT COULD NOT BE REVIVED

AND DECLARED DEATH ON 31/01/25 AT 2:26 AM WITH ECG AHOWING ISOELECTRIC LINE .

IMMEDIATE CAUSE OF DEATH :

- REFRACTORY SHOCK ? CARDIOGENIC ? HEMORRHAGIC SECONDARY TO UPPER BLEED

-DECOMPENSATED CLD WITH PORTAL HYPERTENSION (ASCITES , OESOPHAGEAL

VARICES

-AF WITH FVR

ANTECEDENT CAUSE OF DEATH

-HFREF WITH SEVERE LV DYSFUNCTION SECONDARY TO CAD

-THROMBOCYTOPENIA WITH METABOLIC ACIDOSIS

Death Date

Date:31/01/25

CASE NO : 12

81years/MALE

D. O. A : 01/03/2025

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 CLOXANE

 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 : 13

80years/FEMALE

D. O. A : 18/03/2025

D. O. D :  21/03/2025

Diagnosis

1.HEART FAILURE WITH PRESERVED EJECTION FRACTION

2.ATRIAL FIBRILLATION WITH FAST VENTRICULAR HEART RATE

3.HYPERTENSION

4.ACUTE ACALCULUS CHOLECYSTITIS

Case History and Clinical Findings

C/O PAIN ABDOMEN SINCE 3-4 DAYS

C/O LOOSE STOOLS AND VOMITINGS SINCE 1 DAY

HOPI :

PATIENT WAS APPARENTLY ASYMPTOMATIC 4 DAY AGO THEN DEVELOPED PAIN UPPER

ABDOMEN, INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, COLICKY TYPE,

CONTINUOUS, AGGRAVATED ON FOOD INTAKE, RELIEVED ON MEDICATION ASSOCIATED

WITH VOMITING YESTERDAY 3-4 EPISODES NON PROJECTILE, NON BILIOUS, CONTENT

BEING FOOD PARTICLES, NON FOUL SMELLING

H/O LOOSE STOOLS 6 EPISODE SYESTERDAY WATERY NON FOUL SMELLING NO BLOOD IN

STOOLS.

H/O SOB PRESENT

NO C/O FEVER BURNING MICTURITION

PAST HISTORY :K/C/O HTN SINCE 5-6YEARS ON MEDICATION

N/K/C/O DM ,THYROID ,CAD,CVA ,EPILEPSY ,ASTHMA

PERSONAL HISTORY:

DIET-MIXED

APPETITE- NORMAL

BOWEL MOVEMENTS- REGULAR

BLADDER- REGULAR

SLEEP- ADEQUATE

FAMILY HISTORY : NOT SIGNIFICANT

GENERAL EXAMINATION:

PATIENT IS C/C/C

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

TEMP: AFEBRILE

BP:130/80MMHG

PR:98BPM

RR:18CPM

SPO2 -97 % RA

GRBS :128MG/DL

SYSTEMIC EXAMINATION:

CVS:S1 S2 HEARD ,NO MURMURS

RS:,BAE +,NVBS HEARD

PA: TENDERNESS PRESENT IN EPIGASTRIC REGION AND RIGHT HYPOCHONDRIUM

CNS:NFND

Investigation

COMPLETE BLOOD PICTURE (CBP) HAEMOGLOBIN 8.9 gm/dl 12.0 - 15.0 ColorimetricTOTAL

COUNT 10,100 cells/cumm 4000 - 10000 ImpedenceNEUTROPHILS 64 % 40 - 80 Light

MicroscopyLYMPHOCYTES 21 % 20 - 40 Light MicroscopyEOSINOPHILS 01 % 1 - 6 Light

MicroscopyMONOCYTES 14 % 2 - 10 Light MicroscopyBASOPHILS 00 % 0 - 2 Light

MicroscopyPLATELET COUNT 2.29 lakhs/cu.mm 1.5-4.1 ImpedenceSMEAR Normocytic

normochromic Anemia with Monocytosis

HBsAg-RAPID Negative

Anti HCV Antibodies- RAPID Non Reactive

HIV 1/2 Rapid Test Non Reactive

LIVER FUNCTION TEST (LFT)Test Result Units Normal Range MethodTotal Bilurubin 0.83 mg/dl 0 -

1 Jendrassic &Groff'sDirect Bilurubin 0.20 mg/dl 0.0 - 0.2 Jendrassic &Groff'sSGOT(AST) 179 IU/L 0

- 31 Modified IFCCSGPT(ALT) 135 IU/L 0 - 34 Modified IFCCALKALINE PHOSPHATASE 286 IU/L

56 - 128 PNPP-DEATOTAL PROTEINS 5.6 gm/dl 6.4 - 8.3 BiuretALBUMIN 3.3 gm/dl 3.2 - 4.6

BCGA/G RATIO 1.45

RFTTest Result Units Normal Range MethodUREA 22 mg/dl 17 - 50 Urease-GLDHCREATININE 1.1

mg/dl 0.6 - 1.2 Modified Jaffe'sURIC ACID 2.9 mmol/L 2.6 - 6 Uricase-POD WithDHBSCALCIUM 9.9

mg/dl 8.6 - 10.2 Arsenazo IIIPHOSPHOROUS 4.3 mg/dl 2.5 - 4.5 Direct UV withoutreductionSODIUM

131 mmol/L 136 - 145 Ion Selective ElectrodePOTASSIUM 5.4 mmol/L. 3.5 - 5.1 Ion Selective

ElectrodeCHLORIDE 93 mmol/L 98 - 107 Ion Selective Electrode

USG ABDOMEN DONE ON 183/25

FINDINGS AND IMPRESSION: DIFFUSE WALL THICKENING OF GB WITH MINIMAL

PERICHOLECYSTIC FLUID SUGGESTIVE OF ACUTE CHOLECYSTITIS.

E/O FEW CYSTS NOTED IN MID POLE OF RIGHT KIDNEY - RIGHT SIMPLE RENAL CORTICAL

CYSTS

MINIMAL INTERBOWEL FLUID

2D DONE ON 18/3/25

IMPRESSION

SEVERE TR+ WITH PAH, MODERATE MR+, TRIVIAL AR+/PR+

PARADOXICAL IVS, NO AS/MS. SCLEROTIC AV

FAIR LV SYSTOLIC FUNCTION

GRADE 1 DIASTOLIC DYSFUNCTION, NO LV CLOT

Treatment Given(Enter only Generic Name)

FLUID REPLACEMENT LESS THAN 2 LIT/DAY

SALT RESTRICTION LESS THAN 2 GMS /DAY

T. LASIX 20MG PO/BD

T.METAPROLOL 25MG PO/

T. DAPAGLIFOZIN

T. ECOSPRIN GOLD 75/75/20 PO/HS

INJ. TAXEM 1GM IV/BD

INJ. TRAMADOL 1 AMP IN 100 ML NSIV/ STAT

Advice at Discharge

FLUID REPLACEMENT LESS THAN 2 LIT/DAY

SALT RESTRICTION LESS THAN 2 GMS /DAY

 T. LASIX 20MG PO/BD

T.METAPROLOL 25MG PO/OD

T. DAPAGLIFOZIN 10MG PO/OD

T. ECOSPRIN GOLD 75/75/20 PO/HS

Follow Up

REVIEW TO GENERAL MEDICINE OPD 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 : 14

84years/FEMALE

D. O. A : 22/03/2025

D. O. D : 25/03/2025

Diagnosis

A.FIB

DENOVO HTN

Case History and Clinical Findings

CHEIF COMPLAINTS :

COMPLAINTS OF SOB SINCE 1 YEAR

GENERALIZED WEAKNESS SINCE 1 YEAR

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 YEAR AGO, THEN SHE DEVELOPED

SHORTNESS OF BREATH WHICH WAS INSIDIOUS IN ONSET ,GRADUALLY PROGRESSIVE

,GRADE-II (NYHA) ,NOT ASSOCIATED WITH ANY PALPITATIONS,CHEST

PAIN,COUGH,PND,ORTHOPENA ,AGGRAVATION ON EXERTION AND RELIVING ON REST.

PAST MEDICAL HISTORY:

NO SIMILAR COMPLAINTS IN THE PAST

N/K/C/O DM ,HTN,THYROID,CAD,CVA,EPILEPSY,ASTHMA

FAMILY HISTORY : NOT SIGNIFICANT

GENERAL EXAMINATION:

PATIENT IS C/C/C

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

TEMP: AFEBRILE

BP:140/80MMHG

PR:88BPM

RR:16CPM

GRBS :118MG/DL

SPO2: 98% AT RA

SYSTEMIC EXAMINATION:

CVS:S1 S2 HEARD ,NO MURMURS

RS:BAE +,NVBS HEARD

PA:SOFT,NON TENDER

CNS:NFND

Investigation

HBsAg-RAPID 22-03-2025 04:52:PM -NEGATIVE

Anti HCV Antibodies - RAPID22-03-2025 04:52:PM-NON REACTIVE

COMPLETE BLOOD PICTURE (CBP) 22-03-2025 04:52:PMHAEMOGLOBIN 11.4 gm/dl 15.0-12.0

gm/dlTOTAL COUNT 11900 cells/cumm 10000-4000 cells/cummNEUTROPHILS 73 % 80-40

%LYMPHOCYTES 17 % 40-20 %EOSINOPHILS 01 % 6-1 %MONOCYTES 09 % 10-2

%BASOPHILS 00 % 2-0 %PLATELET COUNT 2.64SMEAR Normocytic normochromic

COMPLETE URINE EXAMINATION (CUE) 22-03-2025 4:52:AMCOLOUR Pale yellowAPPEARANCE

ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NILSUGAR Trace NILBILE SALTS NilBILE

PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS

NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilLIVER FUNCTION TEST (LFT) 22-03-

2025 4:54:PMTotal Bilurubin 0.59 mg/dlDirect Bilurubin 0.19 mg/dlSGOT(AST) 14 IU/LSGPT(ALT) 10

IU/LALKALINE PHOSPHATASE 157 IU/LTOTAL PROTEINS 5.2 gm/dlALBUMIN 3.46 gm/dlA/G

RATIO 1.99

RFT 22-03-2025 4:54:AMUREA 24 mg/dlCREATININE 0.7 mg/dlURIC ACID 2.1 mmol/LCALCIUM

9.1 mg/dlPHOSPHOROUS 2.5 mg/dlSODIUM 141 mmol/LPOTASSIUM 3.3 mmol/L.CHLORIDE 103

mmol/LRFT 23-03-2025 10:55:PMUREA 26 mg/dlCREATININE 0.7 mg/dlURIC ACID 2.7

mmol/LCALCIUM 8.9 mg/dlPHOSPHOROUS 2.9 mg/dlSODIUM 137 mmol/LPOTASSIUM 3.4

mmol/L.CHLORIDE 102 mmol/L

ABG 23-3-2025 10:55:PM

PH : 7.37

PCO2 : 35.4

HC03 :20.4

PO2:73.5

ST.HCO3 : 21.3

BEB: -3.7

BEecf: -3.9

TCO2 : 43.2

O2 SAT: 95.1

O2 COUNT : 12.0

Treatment Given(Enter only Generic Name)

T.MET XL 25 MG PO/OD 1--X--X

T.PANTOP 40 MG PO/OD 1--X--X

T.SHELCAL PO/OD X--1--X

SYP.POTKLOR 15ML-15ML-15ML

T.ECOSPRIN -AV 75/20 MG PO/OD

T.APIXABAN 2.5 MG PO/BD

T.DYTOR PULS LS 10/25 MG PO/OD 1--X--X

Advice at Discharge

T.MET XL 25 MG PO/OD 1--X--X FOR 14 DAYS

T.PANTOP 40 MG PO/OD 1--X--X FOR 14 DAYS

T.ECOSPRIN -AV 75/20 MG PO/OD 1--X--X FOR 14 DAYS

T.APIXABAN 2.5 MG PO/BD 1--X--1 FOR 14 DAYS

T.DYTOR PULS LS 10/25 MG PO/OD 1--X--X FOR 14 DAYS

Follow Up

REVIEW TO GM OPD AFTER 2 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 : 15

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 : 16

85years/FEMALE

D. O. A : 24/06/2025

D. O. D : 25/06/2026

Diagnosis

HEART FAILURE WITH REDUCED EJECTION FRACTION (EF-15%)

DILATED CARDIOMAYOPATHY WITH SEVERE LV DYSFUNCTION

PAROXYSMAL ATRIAL FIBRILLATION CONTROLLED VENTRICULAR RESPONSE

KNOWN CASE OF HEART FAILURE SINCE 10 YEARS

KNOWN CASE OF HYPERTENSION AND TYPE 2 DIABETES MELLITUS SINCE 20 YEARS

Case History and Clinical Findings

C/O BREATHLESSNESS SINCE 2 DAYS,C/O COUGH SINCE 2 DAYS, HISTORY OF PRESENT

ILLNESS PATIENT WAS APPARENTLY ASYMPTOMATIC 2 DAYS BACK AFTER WHICH SHE

DEVELOPED BREATHLESSNESS SUDDEN IN ONSET PROGRESSED TO GRADE IV ,MORE ON

LYING POSITION ASSOCIATED WITH DRY COUGH NO H/O FEVER COLDH/O CONSTIPATION ,

NO H/O PAIN ABDOMEN ,VOMITINGS PAST HISTORY H/O SIMILAR COMPLAINTS IN THE PAST

ON AND OFF SINCE 10 YEARSK/C/O DM-II SINCE 20 YEARSK/C/O HTN SINCE 20 YERAS (ON

UNKNOWN MEDICATION)NO H/O CVA,CAD THYROID DISORDERS,TB,EPILEPSY

PERSONAL HISTORY:

DIET-MIXED APPETITE- NORMALBOWEL -CONSTIPATIONBLADDER- REGULARSLEEPADEQUATE

NO KNOWN ALLERGIES AND ADDICTIONS

GENERAL EXAMINATION:

PATIENT IS C/C/CPALLOR PRESENT

NO,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMATEMP: 98.5FBP:140/100

MMHGPR:102BPMRR:26CPM

SPO2-98% ON ROOM AIRGRBS :122MG/DLSYSTEMIC EXAMINATION:CVS:S1 S2

HEARDRS:,BAE +, NVBS,B/L BASAL CREPTS PRESENTPA:SOFT, NON TENDERCNS:NFND.

DEATH SUMMARY

85-YEAR OLD FEMALE , KNOWN CASE OF HYPERTENSION AND DIABETES –TYPE 2 SINCE 2

YEARS AND KNOWN CASE OF HEART FAILURE SINCE 10 YEARS,CAME TO CASUALTY WITH

COMPAINTS OF COUGH SINCE 2 DAYS AND BREATHLESSNESS SINCE 2DAYS OF GRADE IV

NYHA.AT THE TIME OF PRESENTATION THE VITALS OF PATIENT ARE

TEMPERATURE 98.5F PULSE RATE : 108BPM RESPIRATORY RATE : 26 CPM BLOOD

PRESSURE:140/100MM/HG SPO2:98% @ RA GRBS : 208MG/DL .ON AUSCULTATION

BILATERA; BASAL CREPTS WERE PRESENT AND WAS PROVISIONALLY DIAGNOSED AS

HEART FAILURE AND NECESSARY INVESTIGATIONS WERE SENT AND STARTED ON

SUPPORTIVE TREATMENT

2D ECHO REPORT SHOWED EF: 15% DILATED CARDIOMYOPATHY,SEVEVRE LV

DYSFUNCTION,BILATERAL PLUERAL EFFUSION.

PATIENT WAS ON INJECTION.LASIX AND THERAPEUTIC DOSE OF HEPARIN AND WAS

SHOFTED TO ICU

ON DAY 2 ECG SHOWED PAROXYSMAL ATRIAL FIBRILLATION WITH LEFT BUNDLE BRANCH

BLOCK

PATIENT DEVELOPED BRADYCARDIA AT AROUND 8PM AND FALL IN SATURATION WITH

ABSENT CENTRAL PULSES AT AROUND 10PM

ACCORDING TO ACLS GUIDELINES,CRASH INTUBATION AND RESUSCITATION WAS DONE

.DESPITE ABOVE RESUSCITATION EFFORTS PATIENT COULD NOT BE REVIVED AND WAS

DECLARED DEAD AT 11PM ON 25/06/2025

IMMEDIATE CAUSE OF DEATH - ACUTE MYOCARDIAL INFARCTION WITH COMPLETE HEART

BLOCK

ANTECENT CAUSE OF DEATH- HEART FAILURE WITH REDUCED EJECTION FRACTION WITH

PULMONARY EDEMA,KNOWN CASE OF HYPERTENSION,TYPE 2 DIABETES MELLITUS SINCE

20 YEARS

Investigation

LFT

Total Bilurubin 1.84 mg/dlDirect Bilurubin 0.68 mg/dlSGOT(AST) 93 IU/LSGPT(ALT)

50IU/LALKALINE PHOSPHATASE 305 IU/LTOTAL PROTEINS 6.6gm/dlALBUMIN 3.94gm/dlA/G

RATIO 1.48

Hb 9.0GM/DL

TC - 7000 CEELS/CUMM

PCV - 26VOL%

RBC - 3.57MILLION/CUMM

PL.CT - 4.20 LAKHS/CUMM

RBS 124GM/DL

RFT

urea - 48mg/dl

S.CREAT -1.5mg/dl

URIC ACID -4.7mmol/l

Ca- 10.0mg/dl

Na- 136mm0l/l

K- 4.0mmol/l

Cl -104mmol/l

HBA1C- 6.4%

PT-16 SEC ,INR-1.11.APTT -32SEC

HIV 1/2 RAPID TEST- NON REACTIVE

HbSAg rapid test- NEGATIVE

ANTI HCV ANTOBODIES RAPID TEST-NON REACTIVE

Treatment Given(Enter only Generic Name)

1. Fluid Restriction <1.5 L/day2. Inj. Lasix 3 ml/hr (6 mg) IV infusion FOR 1 DAY3. Inj. Heparin 4000

IU IV/TID 8 AM- 2 PM - 8 PM4. Inj. Dobutamine 3 ml/hr IV infusion FOR 1 DAY5. Inj. Lasix 40MG

IV/BD 8 AM - x - 4 PM7. Inj. HAI S/C TID Premeal acc to GRBS8. Tab. Sacubitril &Valsartan 50 mg

PO/OD9. Tab. Met XL 12.5 mg PO/OD @ 8 AM10. Tab. Ecosprin-AV (75/20) PO/OD @ 8 AM

Death Date

Date: 25/06/2025

CASE NO : 17

68years/FEMALE

D. O. A : 29/01/2024

D. O. D : 05/02/2024

Case History and Clinical Findings

C/O SHORTNESS OF BREATH SINCE 5 DAYS

FEVER SINCE 5 DAYS.

DECREASED URINE OUTPUT SINCE 3 DAYS.

HOPI:

PATIENT WAS APARENTLY ASYMPTOMATIC 10 DAYS BACK, THEN SHE DEVELPOED PEDAL

EDEMA, FEVER, DIAGNOSED OUTSIDE AS RIGHT LOWER LIMB CELLULITIS AND TREATED

ACCORDINGLY.

THEN SHE DEVELOPED SOB SUDDEN IN ONSET AND GRADUALLY PROGRESSIVE GRADE-II

TO IV()MMRC, ORTHOPNEA PRESENT, WHEEZE PRESENT.

FEVER IS LOW GRADE, INTERMITTANT(OCCASIONAL CHILLS+), NO EVENING RISE OF

TEMPERATURE, NO BURNING MICTURITION, COUGH, COLD, PAIN ABDOMEN(CHEST PAIN),

PALPITATIONS.

PAST HISTORY:

K/C/O DM SINCE 7 YEARS UNDER T.GLIMI M1.

K/C/O HTN SINCE 10 YEARS UUNDER T.TELMA AM PO/OD.

NOT A K/C/O TB , EPILEPSY, CVA.

GENERAL EXAMINATIONPATIENT IS CONSCIOUS ,COHERENT ,

COPERATIVETEMPERATURE- AFEBRILEPR 99 BPM

BP 220/110 MMHGSYSTEMIC EXAMINATIONCVS : S1S2 + NO MURMURSRS : BAE+, WHEEZE

+, BILATERAL BASAL CREPTS+.CNS : NFNDP/A : DISTENDED AND NON TENDER , BS +

GENERAL SURGERY REFFERAL WAS DONE ON 29/1/24 I/V/O RIGHT LOWER LIMB SWELLING

?CELLULITIS, AND ADVICED MAGNESIUM SULPHATE DRESISNG , LIMB ELEVATION

OPHTHALMOLOGY REFFERAL WAS DONE ON 29/1/24 I/V/O HYPERTENSIVE RETINOPATHY

CHANGES.

IMPRESSION: NORMAL FUNDUS STUDY.

Investigation

HEMOGRAM

HAEMOGLOBIN -10.4 gm/dl

TOTAL COUNT -8,600 cells/cumm

RBC COUNT- 4.31 millions/cumm

PLATELET COUNT- 2.81 lakhs/cu.mm

IMPRESSION - Microcytic hypochromic Anemia.

BLOOD GROUP : B POSITIVE (+VE)

BLEEDING TIME 2 Min 00 sec

CLOTING TIME 4 Min 00 sec

Prothrombin Time- 16 Sec

INR- 11

APTT TEST 33 SecFBS -98 mg/dL

PLBS -133 mg/dl

HbA1c -6.4 %C-Reactive Protein Negative

E S R - 60 mm/ 1 st hour

ABSOLUTE EOSINOPHIL COUNT -150 cells/cummRFT 29-01-2024

UREA 74 mg/dl

CREATININE 1.6 mg/dl

URIC ACID 6.7 mg/dl

CALCIUM 9.3 mg/dl

PHOSPHOROUS 5.2 mg/dl

SODIUM 136 mEq/L

POTASSIUM 4.2 mEq/L

CHLORIDE 98 mEq/L

LFT 29-01-2024

Total Bilurubin 1.22 mg/dl

Direct Bilurubin 0.36 mg/dl

SGOT(AST) 18 IU/L

SGPT(ALT) 30 IU/L

ALKALINE PHOSPHATASE 126 IU/L

TOTAL PROTEINS 7.0 gm/dl

ALBUMIN 3.77 gm/dl

A/G RATIO 1.17 CUE 29-01-2024

COLOUR 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 3-4

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil HBsAg-RAPID -Negative

Anti HCV Antibodies - RAPID - Non Reactive ABG

PH 7.31

PCO2 15.8

PO2 109

HCO3 7.9

St.HCO3 10.9

BEB -17.3

 BEecf -17.4

TCO2 17.6

O2 Sat 94.9

O2 Count 7.5 HEMOGRAM 30-1-24

HAEMOGLOBIN -10.2 gm/dl

TOTAL COUNT -7,000 cells/cumm

RBC COUNT- 4.19 millions/cumm

PLATELET COUNT- 2.62 lakhs/cu.mm

IMPRESSION - Microcytic hypochromic Anemia.POST LUNCH BLOOD SUGAR 30-01-2024

04:26:PM 133 mg/dl RFT 30-01-2024

UREA 89 mg/dl

CREATININE 1.2 mg/dl

URIC ACID 4.8 mg/dl

CALCIUM 7.1 mg/dl

PHOSPHOROUS 4.2 mg/dl

SODIUM 145 mEq/L

POTASSIUM 3.5 mEq/L

CHLORIDE 105 mEq/L

RFT 31-01-2024

UREA 61 mg/dl

CREATININE 1.6 mg/dl

URIC ACID 9.4 mg/dl

CALCIUM 7.7 mg/dl

PHOSPHOROUS 5.4 mg/dl

SODIUM 143 mEq/L

POTASSIUM 4.1 mEq/L

CHLORIDE 105 mEq/L

HEMOGRAM 31-1-24

HAEMOGLOBIN -9.7 gm/dl

TOTAL COUNT -6,600 cells/cumm

RBC COUNT- 3.98 millions/cumm

PLATELET COUNT- 2.89 lakhs/cu.mm

IMPRESSION - Microcytic hypochromic Anemia.

RETICULOCYTE COUNT - 1.5 %

SERUM IRON -84 ug/dl

D-DIMER- 1500 ng/ml

STOOL FOR OCCULT BLOOD -Negative (-ve)

HEMOGRAM 1-2-24

HAEMOGLOBIN -10.1 gm/dl

TOTAL COUNT -7,500 cells/cumm

RBC COUNT- 4.21 millions/cumm

PLATELET COUNT- 2.92 lakhs/cu.mm

IMPRESSION - Microcytic hypochromic Anemia.D-DIMER 1570 ng/mlHEMOGRAM 4-2-24

HAEMOGLOBIN -11.1 gm/dl

TOTAL COUNT -8000 cells/cumm

RBC COUNT- 4.63 millions/cumm

PLATELET COUNT- 3.09 lakhs/cu.mm

IMPRESSION - microcytic hypochromic blood picture.

RFT 04-02-2024

UREA 40 mg/dl

CREATININE 1.1 mg/dl

URIC ACID 7.9 mg/dl

CALCIUM 10.1 mg/dl

PHOSPHOROUS 4.5 mg/dl

 SODIUM 142 mEq/L

POTASSIUM 3.1 mEq/L

CHLORIDE 103 mEq/L

USG IMPRESSION:

-BILATERAL MILD PLEURAL EFFUSION WITH UNDERLYING COLLAPSED LUNG AND

CONSOLIDATORY CHANGES.

-BILATERAL GRADE-I RPD CHANGES.

-GRADE -I FATTY LIVER.

2D ECHO IMPRESSION:

-(ECCENTRIC TR+) MODERATE TR+ WITH PAH; MILD MR+, TRIVIAL AR+.

-NO RWMA.NO AS/MS, SCLEROTIC AV.

-GOOD LV SYSTOLIC FUNTION.

-DIASTOLIC DYSFUNCTION+.NO LV CLOTS.

REVIEW 2D ECHO IMPRESSION:

-NO RWMA, COCENTRIC LVH+.

- MILD TR+ , MILD MR+ TRIVIAL AR+.

- SCLEROTIC AV. NO AS/MS.

-EF=58%, RVSP2=32+10=42 MM HG

-GOOD LV SYSTOLIC FUNTION.

-MAL+, AML DOMING, PML FIXED.

-DIASTOLIC DYSFUNCTION+.

-IVC SIZE (1.55 CMS), NON COLLAPSING.

-DILATED L.A .

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <1.5L/DAY.

SALT RESTRICTION <2GM/DAY.

INJ.HAI S/C ACCORDING TO GRBS /TID

INJ.LASIX 40MG IV/STAT F/B BD

INJ.AUGMENTIN 1.2 G IV/BD.

INJ.METROGYL 500 MG IV/TID

INJ.PAN 40 MG IV/OD

INJ.HEPARIN 5000IU IV/QID

INJ. ZOFER 4G IV/SOS

NEBULIZATION WITH BUDECORT 2 RESP 8TH HRLY.

T.NICARDIA 20 MG PO/OD X 1 DAY

T.TELMA-H 40+12.5 MG PO/OD (0-0-1)

T.ACITRON 2 MG PO/OD

T.GLIMI -M1 PO/BD (1-0-1)

T.METOPROLOL 25 MG PO/OD

T.LASIX PO/BD 40MG(8AM)-0- 20MG(8PM)

T.CINOD 10 MG PO/HS (0-0-1)

T.PULMOCLEAR PO/BD

T.PAN 40 MG IV/OD (1-0-0)

T.ZOFER 4MG PO/OD (1-0-0)

SYP.ASCORYL-D 10ML PO/TID.

SYP.SUCRALFATE 10ML PO/TID.

Advice at Discharge

T.GLIMI-M1 PO/BD CONTINUE

T.METOPROLOL 25MG PO/OD CONTINUE

T.TELMA-H 40+12.5 MG PO/OD (0-0-1) CONTINUE

T.LASIX PO/BD 40MG(8AM)-0- 20MG(8PM) CONTINUE

T.CINOD 10 MG PO/HS (0-0-1) CONTINUE

T.ACITRON 2 MG PO/OD CONTINUE

T.PAN 40 MG IV/OD (1-0-0) X 5 DAYS

T.ZOFER 4MG PO/OD (1-0-0) X 5 DAYS

SYP.SUCRALFATE 10ML PO/TID X 5 DAYS

Follow Up

REVIEW TO THE GM OPD ON 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 : 18

61years/MALE

D. O. A : 06/01/2024

D. O. D : 10/01/2024

Diagnosis

? COMMUNITY ACQUIRED PNEUMONIA

ANGINA WITH RIGHT BUNDLE BRANCH BLOCK

HEART FAILURE WITH MIDRANGE EJECTION FRACTION

Case History and Clinical Findings

PATIENT CAME TO CASUALITY WITH C/O COUGH, COLD SINCE 3 DAYS

CHEST PAIN SINCE 1 DAY

FEVER SINCE 1 DAY

HOPI

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS BACK THEN HE DEVELOPED COUGH

WITH SPUTUM, SCANTY IN QUANTITY, GREEN IN COLOR ASSOCIATED WITH COLD AND

NASAL BLOCKAGE

H/O FEVER, LOW GRADE, CONTINUOUS NON AGGREVATING WITH NO RELIEVING FACTORS

NO H/O RASH, RETRO ORBITAL PAIN, ARTHRALGIA

C/O CHEST PAIN DIFFUSE SQUEEZING TYPE ASSOCIATED AND AGGREVATED WITH

COUGH, NON-RELIEVING

NO H/O ABDOMINAL PAIN, VOMITING, DIARRHOEA

NO H/O SEIZURES, TREMORS

PAST HISTORY

K/C/O DM, HTN SINCE 10 YEARS ON UNKOWN MEDICATION

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

GENERAL EXAMINATION

PATIENT IS C/C/C

NO PALLOR, ICTERUS, CYANOSIS, LYMPHADENOPATHY, EDEMA

VITALS

TEMPERATURE - 100.8 F

PR - 104 BPM

BP - 110/70

RR - 22 CPM

SPO2 - 93% AT 4L O2

GRBS - 301 MG%

SYSTEMIC EXAMINATION

CVS - S1, S2 HEARD

RS - BAE PRESENT

CNS - NFND

P/A - SOFT, NON TENDER

 BOWEL SOUNDS PRESENT

Investigation

ABG 06-01-2024 08:08:AM

PH 7.39

PCO2 32.1

PO2 62.8

HCO3 19.2

St.HCO3 20.7

BEB -4.4

BEecf -4.8

TCO2 39.5

O2 Sat 91.7

O2 Count 14.3

RFT 06-01-2024 09:19:AM

UREA 42 mg/dl 42-12 mg/dl

CREATININE 1.5 mg/dl 1.3-0.9 mg/dl

URIC ACID 6.0 mg/dl 7.2-3.5 mg/dl

CALCIUM 9.3 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 2.0 mg/dl 4.5-2.5 mg/dl

SODIUM 137 mEq/L 145-136 mEq/L

POTASSIUM 3.9 mEq/L 5.1-3.5 mEq/L

CHLORIDE 103 mEq/L 98-107 mEq/L

LIVER FUNCTION TEST (LFT) 06-01-2024 09:19:AM

Total Bilurubin 0.94 mg/dl 1-0 mg/dl

Direct Bilurubin 0.19 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 22 IU/L 35-0 IU/L

SGPT(ALT) 20 IU/L 45-0 IU/L

ALKALINE PHOSPHATE 213 IU/L 119-56 IU/L

TOTAL PROTEINS 6.3 gm/dl 8.3-6.4 gm/dl

ALBUMIN 3.3 gm/dl 4.6-3.2 gm/dl

A/G RATIO 1.09

HBsAg-RAPID 06-01-2024 09:19:AM Negative

Anti HCV Antibodies - RAPID 06-01-2024 09:19:AM Non Reactive

COMPLETE URINE EXAMINATION (CUE) 06-01-2024 09:19:AM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN +++

SUGAR +

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 2-4

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 07-01-2024 11:00:PM

SODIUM 140 mEq/L 145-136 mEq/L

POTASSIUM 3.8 mEq/L 5.1-3.5 mEq/L

CHLORIDE 102 mEq/L 98-107 mEq/L

CALCIUM IONIZED 1.23 mmol/L mmol/L

COMPLETE BLOOD PICTURE (CBP) 09-01-2024 04:54:AM

HAEMOGLOBIN 9.8 gm/dl 17.0-13.0 gm/dl

TOTAL COUNT 10300 cells/cumm 10000-4000 cells/cumm

NEUTROPHILS 63 % 80-40 %

LYMPHOCYTES 25 % 40-20 %

EOSINOPHILS 02 % 6-1 %

MONOCYTES 10 % 10-2 %

BASOPHILS 00 % 2-0 %

PLATELET COUNT 3.7

SMEAR microcytic hypochromic anemia

RFT 09-01-2024 04:54:AM

UREA 50 mg/dl 42-12 mg/dl

CREATININE 1.9 mg/dl 1.3-0.9 mg/dl

URIC ACID 7.1 mg/dl 7.2-3.5 mg/dl

CALCIUM 10.0 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 4.6 mg/dl 4.5-2.5 mg/dl

SODIUM 139 mEq/L 145-136 mEq/L

POTASSIUM 3.7 mEq/L 5.1-3.5 mEq/L

CHLORIDE 102 mEq/L 98-107 mEq/L

RFT 09-01-2024 11:18:PM

UREA 45 mg/dl 42-12 mg/dl

CREATININE 1.9 mg/dl 1.3-0.9 mg/dl

URIC ACID 7.2 mg/dl 7.2-3.5 mg/dl

CALCIUM 10.1 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 4.2 mg/dl 4.5-2.5 mg/dl

SODIUM 138 mEq/L 145-136 mEq/L

POTASSIUM 3.3 mEq/L 5.1-3.5 mEq/L

CHLORIDE 102 mEq/L 98-107 mEq/L

URINE C/S - NO GROWTH

USG (06/01/2024)

- GRADE 1 FATTY LIVER

- LEFT GRADE 1 RPD CHANGES

2D ECHO (06/01/2024)

- EF - 42%

-CONSECUTIVE LVH

- RWMA +, LAD HYPOKINETIC; RCA AND LCX HYPOKINESIA

- ECCENTRIC TR/MR

- MODERATE MR; MILD-MODERATE AR; MODERATE TR WITH PAH

- SCLEROTIC AV, NO AS/MS

- MODERATE LV DYSFUNCTION PRESENT

- DIASTOLIC DYSFUNCTION PRESENT

- IVC SIZE (1.48CMS) COLLAPSING

- DILATED RA/LA/LV

Treatment Given(Enter only Generic Name)

1) INTERMITTENT CPAP

2) FLUID RESTRICTION <1.5L/DAY

3) SALT RESTRICTION <2.3 GM/DAY

4) INJ. PIPTAZ 4.5GM IV/TID

5) INJ. METROGYL 500MG IV/TID

6)INJ. LASIX 40MG IV/BD

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

8) INJ. PAN 40 IV/OD

9) INJ. HUMAN ACTRAPID S/C BD

10) TAB MET.XL. 25MG PO/OD 9AM

11) TAB CINOD 10MG PO/OD AT 8AM

12) TAB ECOSPRIN.AV 75/10 HS 9PM

13) TAB PCM 650 PO/TID

14) SYP ASCORIL LS 10ML PO/TID

15) NEB WITH BUDECORT 8TH HOURLY

 IPRAVENT 12TH HOURLY

16) BETADINE MOUTH GARGLES TWICE DAILY

Advice at Discharge

1) TAB. LASIX 20MG PO/BD X 10 DAY

2) TAB. MET.XL 25MG PO/OD X 10 DAYS

3) TAB. PAN 40 PO/OD X 10 DAYS

4) TAB. CINOD 10MG PO/OD CONTINUE

5) TAB. ECOSPRIN 75/10 HS X 10 DAYS

6) TAB. PCM 650 PO/SOS

Follow Up

REVIEW 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

CASE NO : 19

74years/MALE

D. O. A : 21/02/2024

D. O. D : 26/02/2024

Diagnosis

HEART FAILURE WITH PRESERVED EJECTION FRACTION

PAROXYSMAL AF

HYPERTENSION SINCE 3 YEARS

Case History and Clinical Findings

C/O SWELLING OF BOTH LOWER LIMBS SINCE 1 WEEK

SHORTNESS OF BREATH SINCE 1 YEAR

DECREASE APPETITE SINCE 1 YEAR

HOPI

PATIENT WAS APPARENTLY ALRIGHT BEFORE 1 WEEK ,HE GRADUALLY DEVELOPED

SWELLING OF BOTH LOWER LIMBS. STARTED INTIALLY IN THE FOOT AND ASCENDS

TOWARDS KNEEJOINTS,THAT IS PITTING IN TYPE

NO H/O TRAUMA/FEVER/DECREASED URINE OUTPUT

-SHORTNESS OF BREATH GRADE 3 IS PRESENT SINCE 1 YEAR WHICH IS GRADUALLY

PROGRESSIVE AND PRESENT EVEN AT REST,PND+,ORTHOPNEA+

-DECREASE IN APPETITE PRESENT SINCE 1 YEAR ASSOCIATED WITH

FLATULENCE,DYSPEPSIA AND CONSTIPATION

NO H/O VOMITINGS,DIARRHEA,PAIN ABDOMEN

PAST HISTORY

K/C/O HTN SINCE 3 YEARS ON TAB AMLONG 5MG OD

NO H/O DM/TB/ASTHMA/EPILEPSY

GENERAL EXAMINATION

PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE.

NO PALLOR, ICTERUS, CLUBBING, CYANOSIS, LYMPHADENOPATHY

ODEMA OF FEET+

TEMPERATURE-98.6

PULSE RATE-80BPM

RR-19CPM

BP-130/90

SPO2-96%

SYSTEMIC EXAMINATION

CVS - S1 S2 HEARD NO MURMURS

RS - BAE+

PA - SOFT, NT

CNS - NO FND

Investigation

POST LUNCH BLOOD SUGAR 21-02-2024 02:59:PM 112 mg/dl 140-0 mg/dl

FBS-111 mg/dl

BLOOD UREA 21-02-2024 02:59:PM 17 mg/dl 50-17 mg/dl

SERUM CREATININE 21-02-2024 02:59:PM 1.3 mg/dl 1.3-0.8 mg/dl

COMPLETE URINE EXAMINATION (CUE) 21-02-2024 02:59:PM

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 1-2

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

SERUM BILIRUBIN

TOTAL BILIRUBIN -1.06mg/dl

DIRECT BILIRUBIN-0.20mg/dl

HEMOGRAM

HAEMOGLOBIN # 13.5gm/dl 12.0 - 15.0

TOTAL COUNT 7600 cells/cumm 4000 - 10000

NEUTROPHILS 66 % 40 - 80

LYMPHOCYTES # 23 % 20 - 40

EOSINOPHILS 03% 01 - 06

MONOCYTES 08 % 02 - 10

BASOPHILS 00 % 0 - 2

PCV # 38.0 vol % 36 - 46

M C V 81.2 fl 83 - 101

M C H 28.8 pg 27 - 32

M C H C 35.5 % 31.5 - 34.5

RDW-CV # 13.1 % 11.6 - 14.0

RDW-SD 39.7 fl 39.0-46.0

RBC COUNT # 4.68 millions/cumm 3.8 - 4.8

PLATELET COUNT 2.05 lakhs/cu.mm 1.5-4.1

RBC Normocytic normochromic

WBC within in normal limits

PLATELETS Adequate in number and distribution

HEMOPARASITES No hemoparasites seen

IMPRESSION normocytic normochromic blood picture

2D ECHO

CONCLUSION

TRIVIAL AR+/TR+.NO PAH,NO MR

NO RWMA

GOOD LV SYSTOLIC FUNCTION

TRIVIAL AR+/TR+,NO PAH

NO PE/CLOTS

Treatment Given(Enter only Generic Name)

1.TAB AMLONG 5MG PO OD

2.TAB LASIX20 MG PO OD

3.NEBULISATION WITH BUDECORT 6TH HOURLY

 WITH IPRAVENT 8 TH HOURLY

4.SYRUP CREMAFFIN PLUS 15 ML PO/HS

Advice at Discharge

1.TAB AMLONG 5MG PO OD TO BE CONTUNIED

2.TAB DITOR PO OD X 2 WEEKS

3.TAB.MET XL 12.5 MG OD AT 8 AM X 2 WEEK

4.TAB.ECOSPRIN EV 75 MG OD AT 2 PM X 2 WEEK

5.TAB CLOPITAB.75 MG OD AT 9 PM X 2 WEEK

6..SYRUP CREMAFFIN PLUS 15 ML PO/HS X 2 WEELKS

7.TAB.CALDARONE 200MG OD X2WEEK

8.TAB.ACITROM 1 MG ODX 2 WEEK

Follow Up

REVIEW TO MEDICINE OPD AFTER 2 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 : 20

71years/MALE

D. O. A : 09/04/2024

D. O. D : 12/04/2024

Diagnosis

HEART FAILURE WITH REDUCED EJECTION FRACTION(35%) SECONDARY TO CAD

LEFT BUNDLE BRANCH BLOCK

K/C/O BRONCHIAL ASTHMA SINCE 30 YRS

K/C/O POST TUBERCULOSIS 30YRS BACK

Case History and Clinical Findings

PATIENT C/O PEDAL EDEMA SINCE 7DAYS

C/O SOB SINCE 3DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 7DAYS BACK THEN DEVELOPED SWELLING

OF BOTH LOWER LIMBS INSIDIOUS IN ONSET PITTING TYPE EXTENDING UPTO KNEES.NO

H/O DECREASED URINE OUTPUT ,FACIAL PUFFINESS ABDOMINAL DISTENSION

C/O SOB INSIDIOUS IN ONSET INITIALLY CLASS II GRADUALLY PROGRESED TO CLASS IV

NYHA

H/O ORTHOPNEA

NO H/O PND,CHESTPAIN,PALPITATIONS,SWEATING

SOB DIURNAL VARIATION - ,SEASONAL VARIATION +, AGGRAVATED IN WINTERS AND RAINY

SEASONS RELIEVES ON TAKING MEDICATIONS

H/O COUGH WITH SCANTY WHITE SPUTUM

K/C/O BRONCHIAL ASTHMA SINCE 30 YRS ,ON REGULAR MEDICATIONS (UNKNOWN)

H/O PULMONARY TB 20YRS BACK , COMPLETED COURSE

N/K/C/O DM,HTN,CVA,SEIZURES

ON EXAMINATION:

PT IS CONSCIOUS,COHERENT,COOPERATIVE

PEDAL EDEMA +

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY

TEMP:96.8 F

BP: 140/80MMHG

PR:96 BPM

RR: 30 CPM

CVS: S1,S2+

CNS : NFND

RS:BLAE+,NVBS+,FINE INSPIRATORY CREPTS+ IN RT ICA,LT ICA,MA,IAA,ISA

GRBS:124MG/DL

PA:SOFT, NT

COURSE IN HOSPITAL : PATIENT WAS ADMITTED IN HOSPITAL IN VIEW OF PEDAL EDEMA

SINCE 7DAYS AND SOB SINCE 3DAYS .PATIENT WAS FURTHER INVESTIGATED WITH ECG

SHOWING LBBB PATTERN AND TROPONIN I WAS SENT ON 09/04/2024 OF VALUE 137.2 AND

PATIENT WAS CONNECTED TO CARDIAC MONITOR ALONG WITH NEBULISATION. REPEAT

ECG'S WERE DONE ALONG WITH REPEAT TOPONIN I SENT ON 10/04/2024 OF VALUE 116.2

.MORNING ECG SHOWS LBBB PATTERN WITH VPC AND PATIENT WAS TREATED

CONSERVATIVELY WITH LASIX INFUSION AND WITH ARB,ORAL ANTIBIOTICS

NEBULISATIONS .PATIENT WAS SYMPTOMATICALLY IMPROVED AND IS BEING DISCHARGED

IN HEMODYNAMICALLY STABLE CONDITION.

Investigation

HEMOGRAM 09/04/24

9/04/24

HEMOGLOBIN 11.2 GM/DL

TLC 12100 CELLS/CUMM

NEUTROPHILS 85 %

LYMPHOCYTES 9%

EOSINOPHILS 01 %

MONOCYTES 05%

BASOPHILS 00 %

PCV 33.8 VOL%

MCV 81.6 FL

MCH 27.1 PG

MCHC 33.1%

RDW-CV 14.1 %

RDW-SD 42.8 FL

RBC COUNT 4.14 MILLIONS/CUMM

PLATELET COUNT 2.5 LAKHS/CU MM

SMEAR

RBC NORMOCYTIC NORMOCHROMIC

WBC INCREASED IN COUNT WITH NEUTROPHILIA

PLATELETS ADEQUATE

HEMOPARASITES NOT SEEN

IMPRESSION NORMOCYTIC NORMOCHROMIC BLOOD PICTURE

ESR 28 MM/1ST HR

ABG 09-04-2024

PH 7.39

PCO2 36.1

PO2 79.6

HCO3 21.7

St.HCO3 22.6

BEB -2.2

BEecf -2.4

TCO2 43.6

O2 Sat 95.7

O2 Count 17.1

RFT 09-04-2024

UREA 60 mg/dl 50-17 mg/dl

CREATININE 1.2 mg/dl 1.3-0.8 mg/dl

URIC ACID 4.2 mmol/L 7.2-3.5 mmol/L

CALCIUM 9.9 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 2.8 mg/dl 4.5-2.5 mg/dl

SODIUM 148 mmol/L 145-136 mmol/L

POTASSIUM 3.7 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 106 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 09-04-2024

TOTAL BILURUBIN 0.86 MG/DL 1-0 MG/DL

DIRECT BILURUBIN 0.18 MG/DL 0.2-0.0 MG/DL

SGOT(AST) 14 IU/L 35-0 IU/L

SGPT(ALT) 11 IU/L 45-0 IU/L

ALKALINE PHOSPHATASE 133 IU/L 119-56 IU/L

TOTAL PROTEINS 5.8 gm/dl 8.3-6.4 gm/dl

ALBUMIN 3.4 gm/dl 4.6-3.2 gm/dl

A/G RATIO 1.45

COMPLETE URINE EXAMINATION (CUE) 09-04-2024

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

HBSAG NON REACTIVE

ANTI HCV NEGATIVE

HIV 1/2 RAPID NEGATIVE

TROPONIN -I ON 09/04/24 : 137.4 PG/ML

 ON 10/04/24 : 116.2 PG/ML

ON 10/04/24

APTT: 30 SEC

PT : 15 SEC

INR : 1.11

CALCIUM 10.2 MG/ DL

ELECTROLYTES NA: 139 MMOL/LIT

 K : 3.6 MMOL/LIT

 CL : 101 MMOL/LIT

 CA IONIZED : 1.10 MMOL/LIT

MAGNESIUM : 2.1 MG/DL

LIPID PROFILE:

T. CHOLESTEROL : 154 MG/DL

TRIGLYCERIDES 52 MG/DL

HDL CHOLESTEROL : 37 MG /DL

LDL :91 MG/ DL

VLDL : 10.4 MG/DL

USG ABDOMEN DONE ON 9/4/24

B/L RENAL CORTICAL CYSTS

B/L GRADE I RPD CHANGES

PROSTATIC CALCIFICATION

HEMOGRAM 11/04/24

HEMOGLOBIN 13.7GM/DL

TLC 11000 CELLS/CUMM

NEUTROPHILS 79 %

LYMPHOCYTES 11%

EOSINOPHILS 03 %

MONOCYTES 07%

BASOPHILS 00 %

PCV 41.8 VOL%

MCV 79.8 FL

MCH 26.1 PG

MCHC 32.7 %

RDW-CV 14.5 %

RDW-SD 43.5 FL

RBC COUNT 5.24 MILLIONS/CUMM

PLATELET COUNT 2.62 LAKHS/CU MM

ECG: LEFT BUNDLE BRANCH BLOCK WITH VPC PRESENT

TROPONIN -I ON 12/04/24 63.5 PG/ML

ELECTROLYTES 12/04/24 NA: 137 MMOL/LIT

 K : 3.3 MMOL/LIT

 CL : 98 MMOL/LIT

 CA IONIZED : 1.06 MMOL/LIT

 UREA

 CREATININE

2D ECHO ON 10/04/24

CONCENTRIC LVH (1.32CMS)

GLOBAL HYPOKINESIA

MILD TO MODERATE MR(MR JET 3.25CMS)

MAC+, ECCENTRIC MR+

MILD AR+

MILD TR+ WITH PAH, RVSP (35+10= 45MMHG)

EF = 35% , MODERATE TO SEVERE LV DYSFUNCTION +

DIASTOLIC DYSFUNCTION+, NO PE

IVC SIZE (0.8CMS) COLLAPSING

DILATED LA, LV.

Treatment Given(Enter only Generic Name)

1) FLUID RESTRICTION <1.5 LIT/DAY

2)INJ. LASIX 40 MG IV/BD

3)INJ . CLEXANE 60 MG IV/OD

4) NEB WITH BUDECORT 8TH HRLY

 WITH IPRAVENT 6TH HRLY

5) TAB AUGMENTIN 625MG PO/TID

6)TAB MET XL 25 MGPO/OD@ 10AM

7)TAB TELMA 20MG PO/OD @ 8AM

8) TAB ECOSPIRIN AV 75/20 PO/HS

9) TAB PAN 40 MG PO/OD /BBF

10) STRICT I/O CHARTING

11) MONITOR VITALS INFORM SOS

Advice at Discharge

1)TAB AUGMENTIN 625MG PO/TID FOR 3DAYS

2)TAB MET XL 12.5 MG PO/OD@ 10AM

3)TAB TELMA 20MG PO/OD @ 8AM

4) TAB ECOSPIRIN AV 75/20 PO/HS

5) TAB PAN 40 MG PO/OD /BBF

6) FORACORT INHALER 200 MG 2 PUFFS PO/BD

7) TAB. LASIX 40MG PO/BD

Follow Up

REVIEW 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 : 21

83years/MALE

D. O. A : 16/12/2024

D. O. D : 20/12/2024

Diagnosis

HEART FAILURE WITH PRESERVED EJECTION FRACTION,

AF WITH CVR

COR PULMONALE

SEVERE TR WITH PAH

B/L PLUERAL EFFUSION(RIGHT>LEFT)

ACUTE EXACERBATION OF COPD (EMPHYSEMA)

K/C/O HTN SINCE 1MONTH

Case History and Clinical Findings

CHEIF COMPLAINTS:-

C/O SWELLING OF BILATERAL LOWER LIMBS SINCE 10DAYS

SOB SINCE 10 DAYS

HOPI:-

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK AND THEN HE DEVELOPED

SWELLING OF LOWER LIMBS SINCE 10 DAYS;BILATERAL PITTING TYPE ;EXTENDING UPTO

KNEE;GRADE IV PITTING; SOB SINCE 10 DAYS; GRADE III MMRC;ORTHOPNEA

PRESENT;PND PRESENT;ASSOCIATED WITH COUGH WITH SPUTUM PRESENT (WHITISHGREEN IN COLOR)

N/H/O FEVER, COLD, COUGH, ALLERGIES, NAUSEA, VOMITING, ABDOMINAL PAIN, CHEST

PAIN, PALPITATIONS, SWEATING, DECREASED URINE OUTPUT, HEADACHE,BURNING

MICTURITION,CONSTIPATION

PAST HISTORY;-

H/O AFIB WITH FVR (2MONTHS BACK)

K/C/O HTN SINCE 1 MONTH AND NOT ON ANY MEDICATION

N/K/C/O DMII,TB,EPILEPSY,ASTHMA,CVA,CAD

PERSONAL HISTORYALCOHOL OCCASIONAL 90ML, STOPPED SNCE 1MONTH

CHUTTA SINCE 30 YRS

GENERAL EXAMINATION :

PATIENT IS C/C/C NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHEDENOPATHY,

EDEMA

BP: 150/80 MMHG

PR: 78 BPM

RR: 18 CPM

SPO2: 98%

SYSTEMIC EXAMINATION :

CVS: S1S2 +

RS: BLAE + B/L FINE CREPTS PRESENT

P/A: SOFT NON TENDER

CNS: NO FND

USG ABDOMEN AND PELVIS DONE ON 16/12/24

IMPRESSION-B/L RAISED ECHOGENICITY OF KIDNEYS

GRADE I PROSTATOMEGALY

B/L PLEURAL EFFUSION WITH UNDERLYING LUNG COLLAPSE AND CONSOLIDATORY

CHANGES.

HRCT OF CHEST DONE ON 17/12/24

IMPRESSION-PROMINENT CARDIAC CHAMBERS

BILATERAL PLEURAL EFFUSION(MODERATE ON RIGHT AND MILD ON LEFT) EXTENDING

INTO FISSURES

SMOOTH INTERLOBULAR SEPTAL THICKENING AND SUBTLE GROUND GLASS

OPACIFICATION IN BOTH LUNGS

2D ECHO DONE ON 16/12/24

EF:-58%

SEVERE TR WITH PAH,MILD TO MODEARTE MR,PR+

PARADOXICAL IVS,NO AS , MILD TO MODERATE MS

GOOD LV SYSTOLIC FUNCTION

NO LV CLOT

CARDILOGY REFERRAL DONE ON 16/12/24 I/V/O 2D ECHO CHANGES

ADVICE-TAB.DYTOR 10MG PO/OD

COURSE IN THE HOSPITAL:-PATIENT WAS PRSENTED TO THE HOSPITAL WITH COMPLAINTS

OF SWELLING OF B/L LOWER LIMBS, SOB,COUGH SINCE 10 DAYS AND FURTHER

INVESTIGATIONS WERE SENT , CHESTXRAY SHOWING B/L PLUERAL EFFUSION

THERAPUETIC PLEURAL TAP WAS DONE, SAMPLE WAS SENT FOR ANALYSIS LIGHTS

CRIERIA SHOWED AS TRANSUDATE AND HRCT WAS DONE TO RULE OUT LUNG

PATHOLOGY,PROMINENT CARDIC CHAMBERS, B/L PLEURAL EFFUSION(MODERATE ON

RIGHT AND MILD ON LEFT SIDE)EXTENDING INTO FISSURES,SMOOTH INTERLOBULAR

SEPTAL THICKENING AND SUBTLE GROUND GLAS OPACIFICATIONS IN BOTH LUNGS SEEN

AND PT WAS TREATED WITH INTERMITTENT CPAP SUPPORT AND 2D ECHO WAS DONE

WHICH SHOWED RIGHT HEART FAILURE WITH SEVER TR WITH PAH WAS PT WAS TREATED

WITH IV.ANTIBIOTIC,DIURETICS,VASODILATORS,HTN MANAGEMNENT, NEBULIZATIONS AND

ADVISED FLUID AND SALT RESTRICTION,PATIENT IS NOW STABLE AND COMPLAINTS ARE

RELIEVED AND PLANNED FOR DISCHARGE.

Investigation

COMPLETE URINE EXAMINATION (CUE) 16-12-2024 11:32:AMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN ++SUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 4-5EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

RFT 16-12-2024 11:32:AMUREA 92 mg/dl 50-17 mg/dlCREATININE 1.3 mg/dl 1.3-0.8 mg/dlURIC

ACID 8.7 mmol/L 7.2-3.5 mmol/LCALCIUM 9.4 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.2 mg/dl 4.5-

2.5 mg/dlSODIUM 143 mmol/L 145-136 mmol/LPOTASSIUM 4.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

104 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 16-12-2024 11:32:AMTotal Bilurubin 0.78 mg/dl 1-0 mg/dlDirect

Bilurubin 0.19 mg/dl 0.2-0.0 mg/dlSGOT(AST) 34 IU/L 35-0 IU/LSGPT(ALT) 17 IU/L 45-0

IU/LALKALINE PHOSPHATASE 162 IU/L 119-56 IU/LTOTAL PROTEINS 7.7 gm/dl 8.3-6.4

gm/dlALBUMIN 3.3 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.77

HBsAg-RAPID 16-12-2024 11:32:AM NegativeAnti HCV Antibodies - RAPID 16-12-2024 11:32:AM

Non Reactive

POST LUNCH BLOOD SUGAR 16-12-2024 11:33:AM 135 mg/dl 140-0 mg/dl

RFT 16-12-2024 10:30:PMUREA 86 mg/dl 50-17 mg/dlCREATININE 1.3 mg/dl 1.3-0.8 mg/dlURIC

ACID 9.0 mmol/L 7.2-3.5 mmol/LCALCIUM 10.1 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 5.0 mg/dl 4.5-

2.5 mg/dlSODIUM 140 mmol/L 145-136 mmol/LPOTASSIUM 4.4 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

101 mmol/L 98-107 mmol/L

T3, T4, TSH 16-12-2024 10:31:PMT3 0.96 ng/ml 1.87-0.87 ng/mlT4 8.35 micro g/dl 12.23-6.32 micro

g/dlTSH 13.7 micro Iu/ml 5.36-0.34 micro Iu/ml

ABG 18-12-2024 12:04:AMPH 7.42PCO2 33.5PO2 51.8HCO3 21.5St.HCO3 22.5BEB -2.1BEecf -

2.3TCO2 45.6O2 Sat 82.6O2 Count 9.5

HEMOGRAM 16/12/24

HAEMOGLOBIN 9.4 gm/dl TOTAL COUNT 5,500 cells/cumm NEUTROPHILS 69 %

LYMPHOCYTES 28 % EOSINOPHILS 02 % MONOCYTES 01 %BASOPHILS 00 % PCV 29.7 vol %

M C V 83.9 fl M C H 26.6 pg M C H C 31.6 % RDW-CV 17.3 % RDW-SD 53.1 fl RBC COUNT 3.54

millions/cummPLATELET COUNT 2.34 lakhs/cu.mm SMEARRBC predominantly

normocyticnormochromic cells seen mildanisocytosis

Total Cholesterol 136 mg/dl CHOD/PODTriglycerides 75 mg/dl HDL Cholesterol 32 mg/dlLDL

Cholesterol 78 mg/dl. VLDL * 15.0 mg/dl

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <1.5L/DAY

SALT RESTRICTION <2GM/DAY

INJ.AUGMENTIN 1.2 GM IV/BD

TAB.AZITHROMYCIN 500MG PO/BD

TAB.METXL 12.5MG PO/OD

TAB.CINOD 10MG PO/OD

TAB.PAN40MG PO/OD

INJ.LASIX 20MG IV/TID

TAB.SILDENAFIL 25MG PO/OD

TAB.ECOSPRIN AV 75 PO/HS

INTERMITTENT CPAP

NEBS WITH BUDECORT-8TH HRLY,IPRAVENT-8TH HRLY

SYP.RAPITUS PLUS 15ML TID

STRICT I/O CHARTING

SYP.SUCRAL-O GEL 10ML PO/TID

INJ.TRAMADOL 1AMP+100M NS IV SLOW OVER 1 HR

Advice at Discharge

FLUID RESTRICTION <1.5L/DAY

SALT RESTRICTION <2GM/DAY

TAB.AZITHROMYCIN 500MG PO/BD

TAB.METXL 12.5MG PO/OD

TAB.CINOD 10MG PO/OD

TAB.PAN40MG PO/OD

TAB.SILDENAFIL 25MG PO/OD

TAB.ECOSPRIN AV 75 PO/HS

SYP.RAPITUS PLUS 15ML TID

SYP.SUCRAL-O GEL 10ML PO/TID

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 : 22

75years/FEMALE

D. O. A : 17/12/2024

D. O. D : 20/12/2024

Diagnosis

HEART FAILURE WITH REDUCED EF (32%?)

CAD- IMP WITH LV ANEURYSM WITH SEVERE LVSD

FUNCTIONAL MR

SECONDARY PULMONARY HYPERTENSION WITH PULMONARY REGURGITATION

PERSISTENT ATRIAL FIBRILLATION WITH FVR

CKD STAGE 3A (EGFR: 44.4ML/MIN/1.73MSQ.)

Case History and Clinical Findings

C/O CHEST PAIN SINCE YESTERDAY

C/O PALPITATIONS SINCE YESTERDAY

C/O BREATHLESSNESS SINCE YESTERDAY

PATIENT WAS APPARENTLY ASYMPTOMATIC TILL YESTERDAY, THEN DEVELOPED CHEST

PAIN, NON RADIATING ASSOCIATED WITH BREATHLESSNESS, GRADE II - III NYHA,

ASSOCIATED WITH PALPITATIONS

H/O FEVER 2 DAYS AGO, HIGH GRADE WITH CHILLS

NO H/O PEDAL EDEMA, ORTHOPNOEA, PND

NO H/O BURNING MICTURITION, COUGH, COLD, VOMITTINGS

PAST HISTORY:

H/O BUNRS TO RIGHT LOWER LIMB DUE TO HOT WATER 2 MONTHS AGO

K/C/O HYPERTENSION SINCE 2 YEARS NOT USING MEDICATION SINCE 2 MONTHS

NO OTHER COMORBIDITIES

PERSONAL HISTORY:

DIET: MIXED

BOWEL AND BLADDER: REGULAR

ADDICTIONS: OCCASIONAL ALCOHOL CONSUMPTION

ALLERGIES: NONE

FAMILY HISTORY: INSIGNIFICANT

GENERAL EXAMINATION:

BP: 110/80 MMHG

PR:121 BPM

RR: 20 CPM

TEMP: AFEBRILE

SPO2: 90% ON RA

GRBS: 112 MG/DL

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

SYSTEMIC EXAMINATION:

CVS: S1 S2+

RS: BAE+ NVBS

CNS: NFND

P/A: SOFT NT, BS+

COURSE:

75 YEAR OLD FEMALE PT CAME WITH C/O CHEST PAIN, PALPITATIONS, BREATHLESSNESS

SINCE YESTERDAY

VITALS: BP: 110/80 MMHG, PR:121 BPM, RR: 20 CPM, TEMP: AFEBRILE, SPO2: 90% ON RA,

GRBS: 112 MG/DL. ECG REVEALED ABSENT P WAVES WITH IRREGULAR HEAR RATE- TAB

MET XL 25 MG WAS GIVEN.

ON FURTHER EVALUATION PT WAS DIAGNOSED AS HEART FAILURE WITH REDUCED EF

(32%?) CAD- IMP WITH LV ANEURYSM WITH SEVERE LVSD FUNCTIONAL MR SECONDARY

PULMONARY HYPERTENSION WITH PULMONARY REGURGITATION PERSISTENT ATRIAL

FIBRILLATION WITH FVR CKD STAGE 3A (EGFR: 44.4ML/MIN/1.73MSQ.)

PT TREATED WITH ANTIBIOTICS, BETA BLOCKERS, DUAL ANTI PLATELETS AND DIURETICS.

PT WAS IMPROVED CLINICALLY AND WAS DISCHARGED IN HEMODYNAMICALLY STABLE

CONDITION.

Investigation

COMPLETE URINE EXAMINATION (CUE) 18-12-2024 12:17:AMCOLOUR 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 Nil

RFT 18-12-2024 12:18:AMUREA 59 mg/dl 50-17 mg/dlCREATININE 1.4 mg/dl 1.2-0.6 mg/dlURIC

ACID 7.0 mmol/L 6-2.6 mmol/LCALCIUM 9.8 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.0 mg/dl 4.5-2.5

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

106 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 18-12-2024 12:18:AMTotal Bilurubin 0.93

mg/dl 1-0 mg/dlDirect Bilurubin 0.20 mg/dl 0.2-0.0 mg/dlSGOT(AST) 31 IU/L 31-0 IU/LSGPT(ALT) 44

IU/L 34-0 IU/LALKALINE PHOSPHATASE 259 IU/L 141-53 IU/LTOTAL PROTEINS 6.0 gm/dl 8.3-6.4

gm/dlALBUMIN 2.73 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.83

HBsAg-RAPID 18-12-2024 12:18:AM NegativeAnti HCV Antibodies - RAPID 18-12-2024 12:18:AM

Non Reactive

HEMOGRAM

HAEMOGLOBIN 8.5 gm/dlTOTAL COUNT 7,800 cells/cumm NEUTROPHILS 78 %LYMPHOCYTES

15 % EOSINOPHILS 01 % MONOCYTES 06 % BASOPHILS 0 % PCV 25.3 vol % M C V 76.4 fl M C

H 25.8 pg M C H C 33.7 % RDW-CV 18.4 % RDW-SD 51.9 fl RBC COUNT 3.32 millions/cumm

PLATELET COUNT 2.19 lakhs/cu.mm SMEARRBC Normocytic normochromic anemia

2D ECHO REPORT: RWMA + LAD TERRITORY AKINETIC RCA AND LCX

HYPOKINETICCONCENTRIL LVH+ (1.33 CM)MODERATE MR+: MODERATE AR+: MILD PR+ (ARDHT-351)MODERATE TR+ WITH PAH SCLEROTIC AV: MV THICKENED; NO AS MS EF= 32%

SEVERE LV DYSFUNCTION GRADE II DIASTOLIC DYSFUNCTION IVC SIZE (1.90 CM) DILATED

NON COLLAPSING ALL CHAMBERS DILATED

USG: ON 19-12-24

IMPRESSION: B/L GRADE 1 RPD CHANGES WITH RPD CHANGES

RT PLEURAL EFFUSION

Treatment Given(Enter only Generic Name)

TAB LINEZOLID 600 MG PO/BD

TAB METROGYL 400 MG PO/TID

TAB MET XL 25 MG PO/BD

TAB DYTOR 10 MG PO/BD

TAB. CLOPITAB A 75/75 PO/OD

TAB ATORVASTATIN 20 MG PO/HS

TAB PAN 40 MG PO/OD

Advice at Discharge

TAB LINEZOLID 600 MG PO/BD X 4 DAYS

TAB METROGYL 400 MG PO/TID X 4 DAYS

TAB TELMISARTAN 20MG PO/OD 8 AM IN MORNING

TAB MET XL 75 MG PO/OD AT 10 AM IN MORNING

TAB. CLOPITAB A 75/75 PO/HS AT 9 PM

TAB ATORVASTATIN 20 MG PO/HS AT 9 PM

TAB SPIRONOLACTONE 25 MG PO/BD

TAB SODOSIS FORTE PO/OD

TAB CHLOR-CAL-D PO/OD

TAB ETDO DEFORTE (IRON) PO/OD AT 4 PM EVENING

TAB PAN 40 MG PO/OD

Follow Up

TO GM OP 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 : 23

60years/MALE

D. O. A : 06/06/2025

D. O. D : 21/06/2025

Diagnosis

NON HEALING ULCER OVER LATERAL ASPECT OF RIGHT KNEE

Case History and Clinical Findings

COMPLAINTS OF ULCER OVER OUTER ASPECT OF RIGHT KNEE SINCE 20 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 20 DAYS AGO , THEN HE HAD TRAUMA (FALL

FROM BED) , THEN HE DEVELOPED A SWELLING AROUND THE RIGHT KNEE FOR WHICH

FASCIOTOMY WAS DONE LATER AFTER 5 DAYS HE DEVELOPED AN ULCER OVER RIGHT

KNEE OUTER ASPECT, PROGRESSIVE IN NATURE, A/W PAIN, PRICKING TYPE, NON

RADIATING, AGGRAVATED ON WALKING, RELEIVED ON TAKING REST, RANGE OF

MOVEMENTS FLEXION AND EXTENSION RESTRICTED.

H/O SEROUS DISCHARGE PRESENT.

H/O FEVER , EVENING RISE OF TEMPERATURE PRESENT.

H/O LOSS OF APPETITE PRESENT.

NO H/O CHRONIC COUGH.

PAST ILLNESS

K/C/O TB DIAGNOSED 7 MONTHS BACK , DISCONTINUED MEDICATION AFTER USING FOR 3

MONTHS.

K/C/O DM SINCE 1 1/2 YRS

K/C/O ASTHMA SINCE 3 YRS NOT ON MEDICATION.

N/K/C/O HTN THYROID DISEASES, CVA, CAD

PERSONAL HISTORY

MARRIED , SELF EMPLOYED , DECREASED APPETITE , MIXED DIET , REGULAR BOWEL AND

BLADDER MOVEMENTS , NO KNOWN ALLERGIES , ADDICTIONS: CHRONIC ALCHOHOLIC

SINCE 40 YRS , REGULAR (90ML/DAY) , BEEDI SINCE 40 YRS (5-6/DAY)

FAMILY HISTORY - NOT SIGNIFICANT

GENERAL PHYSICAL EXAMINATION:

PATIENT IS C/C/C

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING OF FINGERS, GENERALISED

LYMPHADENOPATHY, EDEMA OF FEET

BP:110/60 MMHG

PR:90 BPM

RR: 18 CPM

TEMP: AFEBRILE

SP02: 98 %

SYSTEMIC EXAMINATION:

CVS: S1,S2+

RS: BAE+

CNS:NFND

P/A:SOFT,NT, BS+

LOCAL EXAMINATION

INSPECTION :

AN ULCER OF SIZE 5X4 CM PRESENT ON LATERAL ASPECT OF RIGHT KNEE WITH REGULAR

MARGINS AND SLOPING EDGES. FLOOR IS COVERED WITH SLOUGH.

SEROUS DISCHARGE FROM ULCER PRESENT , FOUL SMELLING.

NO DILATED VEINS.

JOINT MOVEMENTS ARE DECREASED AT RIGHT KNEE.

FASCIOTOMY SCARS ARE PRESENT ON LATERAL AND ANTERIOR ASPECT OF RIGHT LEG

AND ABOVE RIGHT KNEE.

LOSS OF HAIR PRESENT.

PALPATION :

LOCAL RISE OF TEMPERATURE PRESENT .

TENDERNESS PRESENT.

ALL INSPECTORY FINDINGS ARE CONFIRMED REGARDING SIZE , SHAPE , MARGINS.

SLOPING EDGES , ELEVATED MARGINS.

DOESNT BLEED ON TOUCH.

MOBILE OVER DEEPER STRUCTURES.

1 CM DEPTH , BASE IS FORMED BY MUSCLE .

PERIPHERAL PULSES PRESENT.

NO REGIONAL LYMPHADENOPATHY.

NEPHROLOGY REFERRAL DONE ON 07-06-2025

ADVICE : USG ABDOMEN I/V/O RPD CHANGES AND KIDNEY SIZE

2D ECHO I/V/O IVC STATUS

BLOOD AND URINE C/S REPORTS

CARDIOLOGY REFERRAL DONE ON 10-06-2025

TREATMENT : INJ. CORDARONE 150MG BOLUS OVER 10 MINS - INJ. CORDARONE 1 MG/MIN

X 6 HOURS - INJ. CORDARONE 0.5 MG/MIN X 18 HOURS

INJ. LASIX 20 MG IV/BD

TAB. MET XL 50MG PO/OD

TAB. APIXABAN 2.5 MG PO/BD GM REFERRAL DONE ON 10-06-2025

ADVICE -INJ. CORDARONE 150MG BOLUS OVER 10 MINS - INJ. CORDARONE 1 MG/MIN X 6

HOURS - INJ. CORDARONE 0.5 MG/MIN X 18 HOURS

INJ. LASIX 20 MG IV/BD

TAB. MET XL 50MG PO/OD

INJ. HAI S/C TID (ACCORDING TO GRBS)

INJ. PCM 1GM IV/SOS(IF TEMP >101F)

PULMO REFERRAL DONE ON 13-06-2025

ADVICE: HRCT CHEST, INDUCED SPUTUM FOR TRUNAT , C/S , G/S , F/S , F/C , AFB

PSYCHIATRY REFERRAL DONE ON 13-06-2025

TAB. OLANZAPINE 2.5MG (X-X-1)

NICOTINE LOZENGES 2MG/ GUM 2 MG 1-1ORTHO REFERRAL DONE ON 17-06-2025

ADVICE : EFFECTIVE CONTROL OF DIABETES

WOUND CARE

ENCOURAGE ACTIVE AND PASSIVE KNEE MOVEMENTS

REMOVE FOLEY'S CATHETER

FLAP COVER FOR THE WOUND AT LATER DATE.

THERAPEUTIC ANTIBIOTICS AS PER C/S REPORT

Investigation

POST LUNCH BLOOD SUGAR 06-06-2025 04:49:PM 132 mg/dl 140-0 mg/dl

LIVER FUNCTION TEST (LFT) 06-06-2025 04:49:PMTotal Bilurubin 1.01 mg/dl 1-0 mg/dlDirect

Bilurubin 0.24 mg/dl 0.2-0.0 mg/dlSGOT(AST) 40 IU/L 35-0 IU/LSGPT(ALT) 19 IU/L 45-0

IU/LALKALINE PHOSPHATASE 138 IU/L 128-56 IU/LTOTAL PROTEINS 5.6 gm/dl 8.3-6.4

gm/dlALBUMIN 2.1 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.59HBsAg-RAPID 06-06-2025 04:49:PM

Negative

Anti HCV Antibodies - RAPID 06-06-2025 04:49:PM Non ReactiveRFT 06-06-2025 09:39:PMUREA

64 mg/dl 42-12 mg/dlCREATININE 1.7 mg/dl 1.3-0.9 mg/dlURIC ACID 3.4 mmol/L 7.2-3.5

mmol/LCALCIUM 10.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.2 mg/dl 4.5-2.5 mg/dlSODIUM 134

mmol/L 145-136 mmol/LPOTASSIUM 3.0 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 101 mmol/L 98-107

mmol/L

COMPLETE URINE EXAMINATION (CUE) 06-06-2025 10:50:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR +BILE SALTS

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

NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilCOMPLETE BLOOD PICTURE (CBP)

07-06-2025 01:02:PMHAEMOGLOBIN 11.1 gm/dl 17.0-13.0 gm/dlTOTAL COUNT 12700 cells/cumm

10000-4000 cells/cummNEUTROPHILS 68 % 80-40 %LYMPHOCYTES 23 % 40-20

%EOSINOPHILS 00 % 6-1 %MONOCYTES 09 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET

COUNT 2.66SMEAR Leucocytosis

COMPLETE BLOOD PICTURE (CBP) 09-06-2025 12:17:PMHAEMOGLOBIN 12.5 gm/dl 17.0-13.0

gm/dlTOTAL COUNT 18000 cells/cumm 10000-4000 cells/cummNEUTROPHILS 74 % 80-40

%LYMPHOCYTES 18 % 40-20 %EOSINOPHILS 01 % 6-1 %MONOCYTES 07 % 10-2

%BASOPHILS 00 % 2-0 %PLATELET COUNT 2.64SMEAR LeucocytosisRFT 09-06-2025

12:17:PMUREA 26 mg/dl 42-12 mg/dlCREATININE 0.7 mg/dl 1.3-0.9 mg/dlURIC ACID 2.0 mmol/L

7.2-3.5 mmol/LCALCIUM 9.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.4 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 99 mmol/L 98-107

mmol/L

RFT 12-06-2025 12:00:AMUREA 25 mg/dl 42-12 mg/dlCREATININE 0.8 mg/dl 1.3-0.9 mg/dlURIC

ACID 2.0 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 132 mmol/L 145-136 mmol/LPOTASSIUM 2.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

101 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 12-06-2025 12:00:AMTotal Bilurubin 1.79

mg/dl 1-0 mg/dlDirect Bilurubin 0.31 mg/dl 0.2-0.0 mg/dlSGOT(AST) 34 IU/L 35-0 IU/LSGPT(ALT) 14

IU/L 45-0 IU/LALKALINE PHOSPHATASE 166 IU/L 128-56 IU/LTOTAL PROTEINS 5.3 gm/dl 8.3-6.4

gm/dlALBUMIN 1.8 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.54

COMPLETE URINE EXAMINATION (CUE) 12-06-2025 12:00: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 NilSERUM

ELECTROLYTES (Na, K, C l) 12-06-2025 04:34:PMSODIUM 132 mmol/L 145-136

mmol/LPOTASSIUM 3.4 mmol/L 5.1-3.5 mmol/LCHLORIDE 95 mmol/L 98-107 mmol/L

SERUM ELECTROLYTES (Na, K, C l) 13-06-2025 08:19:AMSODIUM 132 mmol/L 145-136

mmol/LPOTASSIUM 3.3 mmol/L 5.1-3.5 mmol/LCHLORIDE 99 mmol/L 98-107 mmol/LRFT 13-06-

2025 11:22:PMUREA 20 mg/dl 42-12 mg/dlCREATININE 0.8 mg/dl 1.3-0.9 mg/dlURIC ACID 1.8

mmol/L 7.2-3.5 mmol/LCALCIUM 10.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.07 mg/dl 4.5-2.5

mg/dlSODIUM 136 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) 16-06-2025 06:23:PMHAEMOGLOBIN 9.3 gm/dl 17.0-13.0

gm/dlTOTAL COUNT 9600 cells/cumm 10000-4000 cells/cummNEUTROPHILS 70 % 80-40

%LYMPHOCYTES 21 % 40-20 %EOSINOPHILS 01 % 6-1 %MONOCYTES 08 % 10-2

%BASOPHILS 00 % 2-0 %PLATELET COUNT 5.1SMEAR Normocytic normochromic anemia with

thrombocytosis

URINE C/S DONE ON 09-06-2025 - NO BACTERIALO GROWTH.

C/S OF SWAB FROM ULCER DONE ON 09-06-2025 - PLENTY OF PUS CELLS , FEW GRAM

NEGATIVE BACILLI SEEN , KLEBSIELLA SPECIES ISOLATED.

2D ECHO DONE ON 10-06-2025

EF: 52 % , IVC SIZE (1.3 CMS) COLLAPSING

MILD TR , NO PAH , TRIVIAL MR/AR , NO PR

PARADOXICAL IVS. NO AS/MS , SCLEROTIC AV .

FAIR LV SYSTOLIC FUNCTION.

GRADE I DIASTOLIC DYSFUNCTION , NO PE, NO LV CLOT

XRAY RIGHT KNEE JOINT (AP AND LATERAL VIEWS) DONE ON 17-06-2025

IMPRESSION: FEW RADIOLUSCENT AREAS IN POSTERO-LATERAL ASPECT OF RIGHT KNEE

JOINT, UNDERLYING BONY CORTEX IS INTACT - ABSCESS

REDUCED LATERAL RIGHT KNEE JOINT SPACE AND FEW OSTEOPHYTES ON MEDIAL AND

LATERAL ASPECT OF RIGHT KNEE JOINT.

OSTEOARTHRITIS CHANGES IN RIGHT KNEE JOINT

USG DONE ON 18-06-2025

IMPRESSION : LARGE VOLUME ECHOGENIC COLLECTION IN INTERMUSCULAR PLANE OF

DISTAL THIGH IN POSTERIOR ASPECT.

SUBCUTRANEOUS COLLECTIONS IN ANTERIOR ASPECT OF DISTAL THIGH ,

ANTEROLATERAL KNEE , ANTEROLATERAL ASPECT OF PROXIMAL AND MID LEG ,

POSTERIOR ASPECT OF MID LEG.

MILD KNEE JOINT EFFUSION WITH SURROUNDING MARGINAL OSTEOPHYTES.

Treatment Given(Enter only Generic Name)

STRICT DIABETIC DIET

3-4 EGG WHITES - PROTEIN DIET

IVF- NS AT 50 ML/HR

INJ. MEROPENEM 1 GM IV/TID

INJ. HAI S/C TID ACCORDING TO GRBS

INJ. PCM 1 GM IV/SOS (IF TEMP >101 F )

TAB. PCM 650 MG PO/QID

TAB. PAN 40 MG PO/OD

TAB. METXL 50 MG PO/OD

TAB. CHYMEROL FORTE PO/TID

TAB. OLANZAPINE 2.5 MG PO/HS

NICOTINE LOZENGES 2 MG/ GUM 2 MG

TAB. MVT PO/OD

TAB. VIT C 500 MG PO/OD

RIGHT LOWER LIMB ELEVATION

Advice at Discharge

STRICT DIABETIC DIET

3-4 EGG WHITES - PROTEIN DIET

TAB. LINEZOLID 600 MG PO/BD X 1 WEEK

TAB. METROGYL 400 MG PO/TID X 1 WEEK

TAB. PCM 650 MG PO/QID X 1 WEEK

TAB. PAN 40 MG PO/OD X 1 WEEK

TAB. METXL 50 MG PO/OD X 1 WEEK

TAB. CHYMEROL FORTE PO/TID X 1 WEEK

TAB. OLANZAPINE 2.5 MG PO/HS X 1 WEEK

NICOTINE LOZENGES 2 MG/ GUM 2 MG X 1 WEEK

TAB. MVT PO/OD X 1 WEEK

TAB. VIT C 500 MG PO/OD X 1 WEEK

RIGHT LOWER LIMB ELEVATION

Follow Up

REVIEW TO GM OPD AFTER 1 WEEK I/V/O DIABETES MELLITUS

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 : 24

70years/FEMALE

D. O. A : 12/07/2025

D. O. D : 19/07/2025

Diagnosis

1.CARDIOGENIC SHOCK WITH

ACUTE PULMONARY EDEMA

ATRIAL FIBRILLATION WITH FVR SECONDARY TO CAD

2.CHRONIC KIDNEY DISEASE

3.K/C/O HYPERTENSION

Case History and Clinical Findings

C/O B/L LOWER LIMB PAIN(MEDIAL SIDE OF FEET SINCE 1MONTH)

B/L LOWER LIMB SWELLING SINCE 1 MONTH

SOB SINCE 1 MONTH

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMNATIC 1 MONTH BACK THEN SHE DEVELOPED B/L

FEET PAIN, BURNNG RELIEVED ON REST

H/O B/L PEDEL EDEMA, GRADE II AGGRAVATEDIN MORNING RELIEVED IN WALKING NO H/O

CHEST PAIN, COUGH, SOB, GIDDINESS ,PALPITATION,HEADACHE,BURNING

MICTUITION,LOOSE MOTION

PAST HISTORY

K/C/O HTN SINCE 5YEARS ON TAB NICARDIA 10MG BD

 TAB ARKAMINE 1MG BD

PERSONAL HISTORY

MARRIED, APPETITE NORMAL,MIXED DIET

REGULAR BOWEL AND BLADDER, NORMAL MICTURITION, NO KNOWN ALLERGIES

NO PALLOR,ICTERUS,CYNOSIS,CLUBBING,LYMPHADENOPATHY,OEDEMA

TEMP 98F,PR 92/MIN,RR20/MIN BP 130/90MMHG,SPO2 96%

SYSTEMIC EXAMINATION:-

CVS: S1,S2 HEARD

NO CARDIAC MURMURS

CNS: NFND

RS:BAE+,NVBS+

P/A: NORMAL,NON TENDER

Investigation

LIVER FUNCTION TEST (LFT) 12-07-2025 Total Bilurubin 1.19 mg/dlDirect Bilurubin 0.26

mg/dlSGOT(AST) 61 IU/LSGPT(ALT) 27 IU/LALKALINE PHOSPHATASE 875 IU/LTOTAL

PROTEINS 5.9 gm/dlALBUMIN 2.68 gm/dlA/G RATIO 0.83

RFT 12-07-2025UREA 94 mg/dlCREATININE 4.0 mg/dlURIC ACID 4.9 mmol/LCALCIUM 10.1

mg/dlPHOSPHOROUS 2.0 mg/dlSODIUM 133 mmol/LPOTASSIUM 4.5 mmol/L.CHLORIDE 96

mmol/LANTI HCV ANTIBODIES (Rapid Test)RAPID 12-07-2025 Non Reactive

HEPATITIS- B SURFACE ANTIGEN (HBSAg) RAPID TEST 12-07-2025 10:45:AM

NegativeCOMPLETE URINE EXAMINATION (CUE) 12-07-2025APPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN ++++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS

CELLS 10-11EPITHELIAL CELLS 3-4RED BLOOD CELLS 2-3CRYSTALS NilCASTS

NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

RFT 15-07-2025UREA 99 mg/dlCREATININE 4.1 mg/dlURIC ACID 7.1 mmol/LCALCIUM 10.0

mg/dlPHOSPHOROUS 2.7 mg/dlSODIUM 134 mmol/LPOTASSIUM 4.5 mmol/L.CHLORIDE 98

mmol/LSERUM ELECTROLYTES 17-07-2025 SODIUM 136 mmol/LPOTASSIUM 4.1

mmol/LCHLORIDE 101 mmol/L

Arterial Blood Gas Analysis (ABG) 17-07-2025PH 7.31PCO2 33.4PO2 35.5HCO3 16.5St.HCO3

17.1BEB -8.5BEecf -8.5TCO2 37.0O2 Sat 56.5O2 Count 4.4LIVER FUNCTION TEST (LFT) 18-07-

2025 Total Bilurubin 1.54 mg/dlDirect Bilurubin 0.64 mg/dlSGOT(AST) 48 IU/LSGPT(ALT) 36

IU/LALKALINE PHOSPHATASE 767 IU/LTOTAL PROTEINS 5.7 gm/dlALBUMIN 1.97 gm/dlA/G

RATIO 0.53

RFT 18-07-2025UREA 84 mg/dlCREATININE 3.4 mg/dlURIC ACID 5.9 mmol/LCALCIUM 9.8

mg/dlPHOSPHOROUS 3.9 mg/dlSODIUM 135 mmol/LPOTASSIUM 4.3 mmol/L.CHLORIDE 99

mmol/LArterial Blood Gas Analysis (ABG) 18-07-2025 PH 7.16PCO2 22.6PO2 67.0HCO3

7.7St.HCO3 9.6BEB -19.4BEecf -19.3TCO2 17.7O2 Sat 85.5O2 Count 8.1

Arterial Blood Gas Analysis (ABG) 18-07-2025 06:56:PMPH 7.13PCO2 27.7PO2 118HCO3

8.9St.HCO3 10.0BEB -18.4BEecf -18.4TCO2 21.2O2 Sat 95.9

Treatment Given(Enter only Generic Name)

SALT RESTRICTION <<1.5 LIT/DAY

FLUID RESTRICTION <2GM/DAY

INJ NORADRENALINE 250MG IN 50 ML NS 15ML/HR

INJ DOBUTAMINE 250MG IN 50ML NS AT 3.6ML/HR

INJ MEDAZOLAM AT 3ML/HR

INJ NEOMOL IV 1GM SOS

TAB NODOSIS 500MG PO/OD

TAB PREGABA M PO/HS

TAB SHELCAL CT PO/OD

TAB OROFER XT PO/OD

TAB MVT PO/OD

MONITOR VITALS INFORM SOS

STRICT I/O CHARTING

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

SIGNATURE OF PATIENT /ATTENDER

SIGNATURE OF PG/INTERNEE

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY

Death Summary

A 65 YEARS OLD FEMALE WHO IS A KNOWN CASE OF CHRONIC KIDNEY DISEASE STAGE V

ON MAINTAINANCE HEMODIALYSIS WAS ADMITTED UNDER NEPHROLOGY FOR

MAINTAINENCE HEMODIALYSIS ON 12/7/25 WITH FOLLOWING VITALS BP 130/90MMHG,PR

90BPM RR 20CPM SPO2 96%ON RA

AS PATIENT CAME FOR MAINTAINANCE HEMODIALYSIS AND HER NEXT SESSION WAS

DATED 14/7/25, PATIENT WENT HOME ON 12/7/25 EVENING. ON 14/7/25PATIENT CAME TO

HOSPITAL WITH COMPALINTS OF SHORTNESS OF BREATH,VITALS BP

120/80,PR110BPM,RR26CPM,SPO2 99% ON RA ECG SHOWED INVERSION OF T WAVES IN V4-

V6AND PATIENTS WAS STARTED O ANTIPLATELET THERAPY PATIENT WAS TAKEN UP

DIALYSIS DURING WHICH SHE DEVELOPD HYPOTENISON (BP:90/60MMHG) INOTROP

NORADRENALIN WAS STARTED AND THEN TAPERED BY 15/7/25 10AM. PATIENT ALSO

DEVELOPED PAROXYSMAL ATRIAL FIBRILATION IN FAST VENTRICULAR RATE RESOLVED

AFTER GIVING BOLUS DOSE OF INJ AMIODARONE (ON 14/7/25AT AROUND 10:30PM)PTIENT

WAS HEMODYNAMICALLY STABLE BY 11AM ON 15/7/25. THEN ON 17/7/25 PATIENT AGAIN

DEVELOPED HYPOTENSION DURING LAST 1HOUR OF HER HEMODIALYSIS SESSION. SHE

WAS STARTED ON SINGLE INOTROPE.AUSCULTATION SHOWED BILATERAL DIFFUSE

COARSE CREPT. ROOM AIR SATURATUIONS WERE FALLING TO 80%,OXYGEN

SUPPLEMTATION,INTERMITTENT CPAP WERE STARTED. DIURETICS WERE GIVEN BY

MAINTAINING. ECG SHOWED IRREGULAR R-R INTERVAL AND P WAVES

ABSENT.SUGGESTIVE OF ATRIAL FIBRILATION AND PATIENT WAS STARTED ON

AMIODARONE INFUSION ON 18/7/25 AT AROUND 5:40PM PATIENTWAS ELECTIVELY

INTUBATED I/V/O INCREASING RESPIRATORY DISTRESS AND HYPOXIA DESPITE NON

INVASIVE VENTILATION DUE TO PERSISTENT HYPOTENSION PATIENT WAS STARTED ON

SECOND INOTROPIC AGENT

AT AROUND 8:0PM PATIENT DEVELOPED SUDDEN BRADYCARDIA CENTRAL AND

PERIPHERAL PULSE WERA ABSENT CPR WAS INITATED FOR 30 MIN DESPITE ABOVE ALL

RESUSCITATORY EFFORTS PATIENT COULDNT BE REVIVED AND DECLARED DEAD AT

9:0PM ON 18/7/25 AFTER ECG SHOWED FLATE LINE

IMMEDIATE CAUSE OF DEATH

TYPE I RESPIRATORY FAILURE SECONDARY TO ACUTE PULMONARY EDEMA

CARDIOGENIC SHOCK

ANTECEDENT CAUSE OF DEATH

HEART FAILURE WITH PRESERVED EJECTION FRACTION WITH ATRIAL FIBRILLATION

SECONDARY TO CORONARY ARTERY DISEASE

CHRONIC KIDNEY DISEASE

K/C/O HYPERTENSION

Discharge Date

Date:19/07/25

CASE NO : 25

80years/FEMALE

D. O. A : 03/07/2025

D. O. D : 16/07/2025

Diagnosis

SEPSIS WITH MODS SECONDARY TO B/L ACUTE PYLONEPHRITIS , S/P B/L DJ STENTING

(30/6)

PAROXYSMAL AF WITH FVR SECONDARY TO SEPSIS

K/C/O HTN, TYPE 2 DM

Case History and Clinical Findings

CHIEF COMPLAINTS

C/O FEVER SINCE 10 DAYS

BURNING MICTURATION SINCE 10 DAYS

HOPI: PT WAS APPARENTY ASYMPTOMATIC UNTIL 10 DAY THAN DEVELOPED ABOVE

COMPLAINS ASSOCIATED WITH CHILLS AND WAS BROUGHT TO CASUALITY FROM OUTSIDE

HOSPITAL.

H/O BURNING MICTURATION , DECREASED URINE OUTPUT, PEDAL EDEMA SINCE 3 DAYS,

NAUSEA, VOMITING, SOB

NO H/O CHEST PAIN, ORTHOPNEA, PND

K/C/O HTN, DMT2

P/H/O CA CERVIX

ON EXAMINATION ;

PATIENT C/C/C

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADEPATHY,ODEMA.

TEMP; 100.5 F

PULSE 102 BPM

RR - 24 CPM

BP;160/70 MMHG

SPO2 ;95% RA

CVS;S1S2 HEARD

RS;BAE , B/L CREPTS

P/A ;SOFT,NON TENDER

CNS: NFND

PERSONAL HISTORY

MIXED DIET

REGULAR BOWEL AND BLADDER MOVEMENTS

NON ALCOHOLIC NON SMOKER

COURSE IN THE HOSPITAL

A 80 YEAR OLD FEMALE PATIENT CAME TO THE CASUALITY FROM OUTSIDE THE HOSPITAL

WITH C/O FEVER SINCE 10 DAYS, C/O BURNING MICTURITION SINCE 10 DAYS, K/C/O HTN,

DM TYPE 2, PAST H/O CERVICAL CANCER 15 YRS AGO. ON PRESENTATION-VITALS: BP

160/70mmHg PR- 102bpm RR-24cpm SpO2-95%@ RA GRBS-212. ALL NECESSARY

INVESTIGATIONS WERE SENT AND DIAGNOSED AS SEPSIS WITH MODS SECONDARY TO B/L

ACUTE PYLONEPHRITIS,PAROXYSMAL AF WITH FVR SECONDARY TO SEPSIS,HEMATURIA

SECONDARY TO URINARY BLADDER HEMATOMA, WAS TREATED WITH 3 SESSION OF

HEMODIALYSIS DONE. PATIENT WAS CONSERVATIVELY MANAGED WITH ANTIBIOTICS

ANTIHYPERTENSIVES.UROLOGY REFERAL WAS DONE IN VIEW OF B/L DJ STENTING DONE

OUTSIDE THE HOSPITAL AND HEMATOMA OF URINARY BLADDER AND THEIR ADVICE WAS

FOLLOWED.AS PATIENT VITALS WERE STABLE PATIENT IS BEING DISCHARGED IN

HEMODYNAMICALLY STABLE CONDITION.

Investigation

COMPLETE URINE EXAMINATION (CUE) 03-07-2025COLOUR Pale yellowAPPEARANCE

ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN traceSUGAR NilBILE SALTS NilBILE

PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS 3-4CRYSTALS

NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

Arterial Blood Gas Analysis (ABG) 03-07-2025PH 7.37PCO2 36.3PO2 70.7HCO3 20.5St.HCO3

21.2BEB -3.7BEecf -3.8TCO2 43.1O2 Sat 93.5O2 Count 12.7HEPATITIS- B SURFACE ANTIGEN

(HBSAg) RAPID TEST 03-07-2025 Negative

ANTI HCV ANTIBODIES (Rapid Test)RAPID 03-07-2025 Non ReactiveRFT 03-07-2025UREA 148

mg/dlCREATININE 3.6 mg/dlURIC ACID 4.9 mmol/LCALCIUM 10.0 mg/dlPHOSPHOROUS 5.3

mg/dlSODIUM 135 mmol/LPOTASSIUM 3.5 mmol/L.CHLORIDE 96 mmol/L

LIVER FUNCTION TEST (LFT) 03-07-2025Total Bilurubin 4.25 mg/dlDirect Bilurubin 3.20

mg/dlSGOT(AST) 41 IU/LSGPT(ALT) 17 IU/LALKALINE PHOSPHATASE 221 IU/LTOTAL

PROTEINS 5.0 gm/dlALBUMIN 2.45 gm/dlA/G RATIO 0.96RFT 03-07-2025UREA 157

mg/dlCREATININE 4.0 mg/dlURIC ACID 5.5 mmol/LCALCIUM 10.0 mg/dlPHOSPHOROUS 5.7

mg/dlSODIUM 134 mmol/LPOTASSIUM 3.4 mmol/L.CHLORIDE 95 mmol/L

Arterial Blood Gas Analysis (ABG) 03-07-2025PH 7.364PCO2 31.2PO2 78.6HCO3 17.4St.HCO3

18.8BEB -6.8BEecf -7.0TCO2 37.4O2 Sat 94.9O2 Count 10.4RFT 04-07-2025UREA 142

mg/dlCREATININE 3.5 mg/dlURIC ACID 4.9 mmol/LCALCIUM 10.1 mg/dlPHOSPHOROUS 5.9

mg/dlSODIUM 135 mmol/LPOTASSIUM 3.4 mmol/L.CHLORIDE 98 mmol/L

RFT 05-07-2025UREA 156 mg/dlCREATININE 3.7 mg/dlURIC ACID 6.0 mmol/LCALCIUM 10.1

mg/dlPHOSPHOROUS 6.1 mg/dlSODIUM 135 mmol/LPOTASSIUM 4.0 mmol/L.CHLORIDE 98

mmol/LRFT 06-07-2025UREA 156 mg/dlCREATININE 3.4 mg/dlURIC ACID 6.0 mmol/LCALCIUM

10.0 mg/dlPHOSPHOROUS 6.4 mg/dlSODIUM 135 mmol/LPOTASSIUM 3.6 mmol/L.CHLORIDE 98

mmol/L

HEMOGRAM 04-07-2025

HAEMOGLOBIN 9.8 gm/dl 12.0 - 15.0 Colorimetric LOX -PAPTOTAL COUNT 16,900 cells/cumm

4000 - 10000 ImpedenceNEUTROPHILS 87 % 40 - 80 Light MicroscopyLYMPHOCYTES 06 % 20 -

40 Light MicroscopyEOSINOPHILS 00 % 01 - 06 Light MicroscopyMONOCYTES 07 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 27.2 vol % 36 - 46 CalculationM C V 62.3 fl

83 - 101 CalculationM C H 22.5 pg 27 - 32 CalculationM C H C 36.1 % 31.5 - 34.5 CalculationRDWCV 24.2 % 11.6 - 14.0 HistogramRDW-SD 53.5 fl 39.0-46.0 HistogramRBC COUNT 4.36

millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 1.30 lakhs/cu.mm 1.5-4.1

ImpedenceSMEARRBC microcytic hypochromic Light MicroscopyWBC incresed counts on smear

withincresed neutrophilsLight MicroscopyPLATELETS in Adeqaute Light

MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION microcytic

hypochromic anemiawith neutrophilic leukocytosis andthrombocytophenia

HEMOGRAM 05-07-2025

HAEMOGLOBIN 9.1 gm/dl 12.0 - 15.0 Colorimetric LOX -PAPTOTAL COUNT 17,500 cells/cumm

4000 - 10000 ImpedenceNEUTROPHILS 82 % 40 - 80 Light MicroscopyLYMPHOCYTES 08 % 20 -

40 Light MicroscopyEOSINOPHILS 02 % 01 - 06 Light MicroscopyMONOCYTES 08 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 25.9 vol % 36 - 46 CalculationM C V 63.3 fl

83 - 101 CalculationM C H 22.2 pg 27 - 32 CalculationM C H C 35.0 % 31.5 - 34.5 CalculationRDWCV 25.3 % 11.6 - 14.0 HistogramRDW-SD 56.4 fl 39.0-46.0 HistogramRBC COUNT 4.09

millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 1.52 lakhs/cu.mm 1.5-4.1

ImpedenceSMEARRBC microcytic hypochromic Light MicroscopyWBC neutrophilic leukocytosis Light

MicroscopyPLATELETS Adeqaute Light MicroscopyHEMOPARASITES No hemoparasites seen Light

MicroscopyIMPRESSION microcytic hypochromic anemiawith neutrophilic leukocytosis

Arterial Blood Gas Analysis (ABG) 06-07-2025PH 7.34PCO2 35.8PO2 24.9HCO3 19.2St.HCO3

19.2BEB -5.4BEecf -5.4TCO2 41.8O2 Sat 32.4O2 Count 3.6RFT 08-07-2025UREA 99

mg/dlCREATININE 2.4 mg/dlURIC ACID 3.9 mmol/LCALCIUM 9.9 mg/dlPHOSPHOROUS 4.9

mg/dlSODIUM 137 mmol/LPOTASSIUM 3.7 mmol/L.CHLORIDE 101 mmol/L

HEMOGRAM 07-07-2025

HAEMOGLOBIN 8.2 gm/dl 12.0 - 15.0 Colorimetric LOX -PAPTOTAL COUNT 16,800 cells/cumm

4000 - 10000 ImpedenceNEUTROPHILS 86 % 40 - 80 Light MicroscopyLYMPHOCYTES 06 % 20 -

40 Light MicroscopyEOSINOPHILS 01 % 01 - 06 Light MicroscopyMONOCYTES 07 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 23.6 vol % 36 - 46 CalculationM C V 64.6 fl

83 - 101 CalculationM C H 22.4 pg 27 - 32 CalculationM C H C 34.7 % 31.5 - 34.5 CalculationRDWCV 25.6 % 11.6 - 14.0 HistogramRDW-SD 58.6 fl 39.0-46.0 HistogramRBC COUNT 3.65

millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 2.89 lakhs/cu.mm 1.5-4.1

ImpedenceSMEARRBC Microcytic hypochromic Light MicroscopyWBC increased counts on smear

withneutrophiliaLight MicroscopyPLATELETS Adequate in number and distribution Light

MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Microcytic

hypochromic anemia withneutrophilic leucocytosis

LIVER FUNCTION TEST (LFT) 08-07-2025Total Bilurubin 1.70 mg/dlDirect Bilurubin 1.31

mg/dlSGOT(AST) 87 IU/LSGPT(ALT) 64 IU/LALKALINE PHOSPHATASE 392 IU/LTOTAL

PROTEINS 5.3 gm/dlALBUMIN 2.7 gm/dlA/G RATIO 1.04LIVER FUNCTION TEST (LFT) 08-07-

2025Total Bilurubin 2.45 mg/dlDirect Bilurubin 1.41 mg/dlSGOT(AST) 69 IU/LSGPT(ALT) 61

IU/LALKALINE PHOSPHATASE 385 IU/LTOTAL PROTEINS 5.7 gm/dlALBUMIN 2.88 gm/dlA/G

RATIO 1.02

RFT 08-07-2025UREA 88 mg/dlCREATININE 2.2 mg/dlURIC ACID 4.2 mmol/LCALCIUM 10.1

mg/dlPHOSPHOROUS 5.4 mg/dlSODIUM 136 mmol/LPOTASSIUM 4.1 mmol/L.CHLORIDE 94

mmol/L

HEMOGRAM 08-07-2025

HAEMOGLOBIN 7.8 gm/dl 12.0 - 15.0 Colorimetric LOX -PAPTOTAL COUNT 13,400 cells/cumm

4000 - 10000 ImpedenceNEUTROPHILS 85 % 40 - 80 Light MicroscopyLYMPHOCYTES 07 % 20 -

40 Light MicroscopyEOSINOPHILS 01 % 01 - 06 Light MicroscopyMONOCYTES 07 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 22.7 vol % 36 - 46 CalculationM C V 65.1 fl

83 - 101 CalculationM C H 22.3 pg 27 - 32 CalculationM C H C 34.2 % 31.5 - 34.5 CalculationRDWCV 26.0 % 11.6 - 14.0 HistogramRDW-SD 66.6 fl 39.0-46.0 HistogramRBC COUNT 3.49

millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 3.49 lakhs/cu.mm 1.5-4.1

ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light

MicroscopyPLATELETS Adeqaute Light MicroscopyHEMOPARASITES No hemoparasites seen Light

MicroscopyIMPRESSION Microcytic hypochromic anemia withneutrophilic leucocytosis

HEMOGRAM 09-07-2025

HAEMOGLOBIN 10.1 gm/dl 12.0 - 15.0 Colorimetric LOX -PAPTOTAL COUNT 14,000 cells/cumm

4000 - 10000 ImpedenceNEUTROPHILS 90 % 40 - 80 Light MicroscopyLYMPHOCYTES 07 % 20 -

40 Light MicroscopyEOSINOPHILS 00 % 01 - 06 Light MicroscopyMONOCYTES 03 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 29.1 vol % 36 - 46 CalculationM C V 71.2 fl

83 - 101 CalculationM C H 24.7 pg 27 - 32 CalculationM C H C 34.8 % 31.5 - 34.5 CalculationRDWCV 34.4 % 11.6 - 14.0 HistogramRDW-SD 90.0 fl 39.0-46.0 HistogramRBC COUNT 4.09

millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 3.5 lakhs/cu.mm 1.5-4.1

ImpedenceSMEARRBC Microcytic hypochromic Light MicroscopyWBC Increased counts on smear

withneutrophiliaLight MicroscopyPLATELETS Adequate in number and distribution Light

MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Microcytic

hypochromic anemia withneutrophilic leucocytosis

USG DONE ON 07-06-2025

GRADE II RPD CHANGES OF RIGHT KIDNEY

GRADE I RPD CHANGES OF LEFT KIDNEY

HEMOGRAM ON 10/07/25

HAEMOGLOBIN 9.1 gm/dl 12.0 - 15.0 Colorimetric LOX -PAPTOTAL COUNT 10,200 cells/cumm

4000 - 10000 ImpedenceNEUTROPHILS 79 % 40 - 80 Light MicroscopyLYMPHOCYTES 11 % 20 -

40 Light MicroscopyEOSINOPHILS 02 % 01 - 06 Light MicroscopyMONOCYTES 08 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 25.5 vol % 36 - 46 CalculationM C V 68.9 fl

83 - 101 CalculationM C H 24.6 pg 27 - 32 CalculationM C H C 35.7 % 31.5 - 34.5 CalculationRDWCV 32.4 % 11.6 - 14.0 HistogramRDW-SD 87.2 fl 39.0-46.0 HistogramRBC COUNT 3.70

millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 4.90 lakhs/cu.mm 1.5-4.1

ImpedenceSMEARRBC Anisocytosis with microcytichypochromic and normocytesLight

MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Increased counts on smear Light

Microscop

RFT ON 10/07/25

UREA 50 mg/dl 17 - 50 Urease-GLDHCREATININE 1.6 mg/dl 0.6 - 1.2 Modified Jaffe'sURIC ACID

3.2 mmol/L 2.6 - 6 Uricase-POD WithDHBSCALCIUM 10.0 mg/dl 8.6 - 10.2 Arsenazo

IIIPHOSPHOROUS 4.1 mg/dl 2.5 - 4.5 Direct UV withoutreductionSODIUM 135 mmol/L 136 - 145 Ion

SelectiveElectrodePOTASSIUM 3.1 mmol/L. 3.5 - 5.1 Ion SelectiveElectrodeCHLORIDE 98 mmol/L

98 - 107 Ion Selecti

CUE ON 10/07/25 :

COLOUR Reddish Pale Yellow PhysicalExaminationAPPEARANCE Cloudy Clear

PhysicalExaminationREACTION Acidic 5.0-9.0 Reagent StripSP.GRAVITY 1.010 1.001-1.035

Reagent StripALBUMIN ++++ Negative Reagent StripSUGAR + Negative Reagent StripBILE SALTS

Nil Negative Reagent StripBILE PIGMENTS Nil Negative Reagent StripPUS CELLS 1-2 0-5/HPF

Light MicroscopyEPITHELIALCELLS1-2 0-5/HPF Light MicroscopyRED BLOODCELLSplenty 0-

2/HPF Light MicroscopyCRYSTALS Nil Nil Light MicroscopyCASTS Nil Nil Light

MicroscopyAMORPHOUSDEPOSITSAbsent Nil Light MicroscopyOTHERS yeast forms prasent Nil

Light Microscopy

HEMOGRAM ON 11/07/25

HAEMOGLOBIN 8.3 gm/dl 12.0 - 15.0 Colorimetric LOX -PAPTOTAL COUNT 9,700 cells/cumm

4000 - 10000 ImpedenceNEUTROPHILS 78 % 40 - 80 Light MicroscopyLYMPHOCYTES 12 % 20 -

40 Light MicroscopyEOSINOPHILS 01 % 01 - 06 Light MicroscopyMONOCYTES 09 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 25.8 vol % 36 - 46 CalculationM C V 74.2 fl

83 - 101 CalculationM C H 23.9 pg 27 - 32 CalculationM C H C 32.2 % 31.5 - 34.5 CalculationRDWCV 31.8 % 11.6 - 14.0 HistogramRDW-SD 86.1 fl 39.0-46.0 HistogramRBC COUNT 3.47

millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 4.2 lakhs/cu.mm 1.5-4.1

ImpedenceSMEARRBC Anisocytosis with Microcytichypochromic and normocytesLight

MicroscopyWBC counts with in normal limits Light MicroscopyPLATELETS Increased counts on

smear Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION

Microcytic hypochromic anemia withthrombocytosis. Assay results should be interpreted only in the

context of other laboratory findings and the total clinical status of the patient.. This report is subjected

to the terms and conditions mentioned overleaf.*PARTIAL REPRODUCTION OF THE REPORT IS

NOT PERMITTED.-- END

RFT ON 11/07/25

UREA 62 mg/dl 17 - 50 Urease-GLDHCREATININE 1.8 mg/dl 0.6 - 1.2 Modified Jaffe'sURIC ACID

3.7 mmol/L 2.6 - 6 Uricase-POD WithDHBSCALCIUM 10.0 mg/dl 8.6 - 10.2 Arsenazo

IIIPHOSPHOROUS 3.9 mg/dl 2.5 - 4.5 Direct UV withoutreductionSODIUM 138 mmol/L 136 - 145 Ion

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

98 - 107 Ion SelectiveElectrode

HEMOGRAM 15/7/25

HEMOGLOBIN 11.6 gm/dl

TOTAL COUNT 10700 cells/cumm

NEUTROPHILS 76%

LYMPHOCYTES 15%

EOSINOPHILS 04%

MONOCYTES 05%

BASOPHILS 00%

PCV 36.4 vol%

MCV 77.9%

MCH 24.8%

MCHC 31.8 %

RDW-CV 30.1

RDW-SD 80.8

RBC COUNT 4.6 million/cumm

PLATELET COUNT 3.0 lakhs/cumm

SMEAR

RBC NORMOCYTIC NORMOCHROMIC

WBC WITHIN NORMAL LIMITS

PLATELETS ADEQUATE

NO HEMOPARASITES SEEN

IMPRESSION NORMOCYTIC NORMOCHROMIC BLOOD PICTURE

RFT 15/7/25

UREA 51mg/dl

CREATININE 1.3mg/dl

CALCIUM 10.0mg/dl

PHOSPHORUS 3.2mg/dl

SODIUM 135mmol/L

POTASSIUM 4.1mmol/L

CHLORIDE 98mmol/L

Treatment Given (Enter only Generic Name)

INJ.MEROPENUM.SALBALTUM 750ML IV/BD

INJ.CLINDAMYCIN 600MG IV/TID

INJ.NEOMOL 1GM IV/SOS IF TEMP >101F

INJ. PAN 40MG IV/OD

INJ HAI SC/TID ACC TO GRBS

T.PCM 650MG PO/TID

T.ZOFER 4 MG PO/OD

T.AMLODIPINE 5MG PO/OD

SYP. POTCHLOR 10ML PO/TID

STRICT I/O CHARTING

GRBS 70 PROFILE

MONITOR VITALS INFORM SOS

Advice at Discharge

T.PCM 650MG PO/TID FOR 3 DAYS

T.PAN 40 MG FOR 5 DAYS

T.AMLODIPINE 5MG PO/OD TO BE CONTINUED

TAB.ZOFER 4MG PO/OD FOR 5 DAYS

TAB OROFER XT PO/OD FOR 1 MONTH

TAB.SHELCAL CT PO/OD FOR 1 MONTH

TAB NEUROBIONE FORTE PO/OD FOR 1 MONTH

SYP. POTCHLOR 10ML PO/TID FOR 5 DAYS

Follow Up

REVIEW TO NEPHROLOGY OPD AFTER 7 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:

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.