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12.

 Case History and Clinical Findings

A 56 YEAR OLD FEMALE WITH CHIEF COMPLAINTS: C/O ALTERED SENSORIUM SINCE MORNING.

SHORTNESS OF BREATH SINCE 2 DAYS

VOMITINGS SINCE 2 DAYS

LOOSE STOOLS SINCE 2 DAYS

DECREASED URINE OUTPUT SINCE YESTERDAY.

HOPI:

PT WAS APPARENTLY ASYMPTOMATIC 2 DAYS BACK THEN CAME FROM WORK AND AT 12

AM PT HAD SUDDEN ONSET OF SHORTNESS OF BREATH GRADE 4 ASSOCIATED WITH

VOMITINGS 5-6 EPISODES CONTAINING FOOD PARTICLES INITIALLY, LATER CONTAINED

MUCOUS AND ASSOCIATED WITH LOOSE STOOLS, 10 EPISODES, SMALL VOLUME , WATERY

CONSISTENCY, GREEN COLOURED , NON MUCOID AND NON BLOOD STAINED. NEXT DAY

MORNING PATIENT WAS TAKEN TO LOCAL RMP, WHERE 2 NS WEREGIVEN AND 2

INJECTIONS WERE GIVEN AND SENT HOME. AFTER GOING HOME, PT WAS GIVEN

COCONUT WATER AND 2 EPISODES OF VOMITINGS AND FOLLOWING 1 HR (CURD RICE

WAS GIVEN)

NO FURTHER VOMITINGS AND LOOSE STOOLS NOTED.

NEXT DAY MORNING ONWARDS, PT WAS DROWSY, BUT RESPONDING TO COMMANDS,

BROUGH HERE FOR FURTHER EVALUATION.

NO H/O FEVER AND BURNING MICTURITION.

PAST HISTORY:

K/C/O HTN SINCE 5-6 YRS (ON IRREGULAR MEDICATION NOT KNOWN)

H/O ADMISSION AT OTHER HOSPITAL (?RT LOWERLIMB CELLULITIS) AND GOT

DISCHARGED.

NOT A K/C/O DM, CAD, CVD, ASTHMA, TB, EPILEPSY.

PERSONAL HISTORY:

DIET: VEGETARIAN

APPETITE:NORMAL

BOWEL AND BLADDER MOVEMENTS:REGULAR

ADDICTIONS: OCCASIONAL TODDY

NON SMOKER

FAMILY HISTORY:

INSIGNIFICANT

GENERAL EXAMINATION:

PT DROWSY BUT AROUSABLE

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

TEMP:102F

PR:98BPM

RR:22CPM

BP:80/60MMHG

SPO2:90%

GRBS:65MG/DL

CVS: S1 S2 +

NO MURMURS

RS:BAE+, NVBS

PER ABDOMEN:DISTENDED AND NON TENDER

CNS:

PT IS DROWSY

SPEECH SLURRED

NFND

Investigation

USG ON 24/1/23

IMPRESSION:

GRADE 2 FATTY LIVER

REVIEW USG ON 28/1/23

IMPRESSION:

GRADE 2 FATTY LIVER WITH HEPATOMEGALY

GB SLUDGE

MESENTERIC LYMPHADENOPATHY

HRCT OF THROAX:

IMPRESSION:

MILD TO MEDERATE PLEURAL EFFUSION WITH BASAL ATELECATASIS

FEW NODULAR OPACITIES SEEN IN LEFT LUNG MAINLY IN UPPER LOBE (INFECTIVE

ETIOLOGY)

HEPATIC STENOSIS

2D ECHO ON 28/1/23

CONCENTRIC LVH +

NO RWMA MILD MR+/AR+

SCLEROTIC AV, NO AS, MS

EF=58

GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION +, NO PE

IVC SIZE (1.48CMS)

HB-6.5-6.3-7.6-7.5-7.3-7.2

TLC-11,800-15,500-13,400-14,900-16,600-14,900

PLATELET-1.80-1.80-1.90-1.96-1.78-1.61


Diagnosis

?SEPTIC ENCEPHALOPATHY (RESOLVING)

?UREMIC ENCEPHALOPATHY (RESOLVING)

SEPTIC SHOCK WITH MODS (AKI, ALI)

ACUTE RESPIRATORY DISTRESS SYNDROME

MULTIFOCAL ATRIAL TACHYCARDIA (RESOLVED)

SEPTIC SHOCK(RESOLVED) SECONDARY TO RIGHT LOWER LIMB CELLULITIS

TYPE 1 RESPIRATORY FAILURE SECONDARY TO NON CARDIOGENIC PULMONARY EDEMA

?ATYPICAL PNEUMONIA

S/P 6 SESSIONS OF HEMODIALYSIS

GRADE 3 BEDSORE

?SUBMASSIVE PULMONARY EMBOLISM

HTN+ DM


Treatment Given(Enter only Generic Name)

NEB. DUOLIN 8TH HOURLY

BUDECORT 12TH HOURLY

MUCOMIST 12TH HOURLY

IV FLUIDS 2 NS @150ML/HR

1 RL @150ML/HR

1 DNS @150ML/HR

INJ MEROPENEM 500MG IV BD FOR 7 DAYS

INJ LASIX 40MG IV BD

INJ PAN 40 MG IV OD

INJ ZOFER 4MG IV SOS

INJ NEOMOL 1 GM IV SOS (IF TEMP >101F)

TAB. DOXY 100MG RT BD FOR FOR 7 DAYS

TAB.PIRFENIDONE 200MG RT BD FOR 5 DAYS

T. MET-XL 25MG RT OD

T.SHELCAL-CT RT OD

T.PCM 650MG RT BD

T.SPOROLAC-DS RT TID

SYP.ASCORYL LS 10ML RT TID

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

OINT THROMBOPHOBE GEL L/A BD

3 PRBC TRANSFUSION DONE


Advice at Discharge

NEBULISATION WITH DUOLIN 8TH HRLY

NEB BUDECORT 12TH HRLY

WITH MUCOMIST 12TH HRLY

TAB LASIX 40MG PO BD 8AM-8PM

TAB PAN 40 MG PO OD 7AM BEFORE FOOD

TAB MET XL 25MG PO OD AT 8AM

TAB.PIRFENIDONE 200MG PO BD 8AM AND 8PM

T. SHELCAL CT PO OD AT 8AM

T. PCM 650MG PO BD AT 8AM AND 8PM

T.ZOFER 4MG PO SOS

SYP.ASCORYL LS 10ML PO BD AT 8AM AND 8PM

THROMBOPHOBE OINTMENTFOR L/A AT 8AM AND 8PM

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