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15

 Case History and Clinical Findings

60 YEAR OLD FEMALE PATIENT WAS BROUGHT TO CASUALITY WITH C/O PAIN ABDOMEN SINCE LAST MIGHT,

DECREASED URINE OUTPUT SINCE LAST NIGHT

HISTORY OF PRESENT ILLNESS:-

PATIENT WAS APPARENTLY NORMAL 1 DAY BACK THEN DEVELOPED PAIN ABDOMEN

DRAGGING TYPE NON RADIATING LOCALISED TO UMBILICAL REGION

ASSOCIATED WITH 2 EPISODES OF VOMITINGS WATERY NON BILIOUS NON PRTOJECTILE

WITH FOOD PARTICLES AS CONTENTS

C/O DECREASED URINE OUTPUT SINCE LAST NIGHT

H/O FEVER 3 DAYS BACK HIGH GRADE INTERMITTENT ASSOCIATED WITH CHILLS AND

RIGORS RELIEVED BY MEDICATION

C/O PAIN IN LEFT LOWER LIMB, SWELLING PRESENT, PITTING TYPE, EXTENDING UPTO THE

KNEE, TENDERNESS PRESENT

C/O SHORTNESS OF BREATH SINCE LAST NIGHT

NO C/O CHESTPAIN,PALPITATIONS, ORTHOPNEA, PND, LOOSE STOOLS AND FACIAL

PUFFINESS

PAST HISTORY:-

PATIENT IS A K/C/O HYPERTENSION SINCE 5 YEARS USING TAB.ATENOLOL 50MG OD N/K/C/O DM, TB, EPILEPSY, CVA, CAD, THYROID DISORDERS

PERSONAL HISTORY:

APPETITE - NORMAL

BOWELS - REGULAR

MICTURITION - NORMAL

NO ALLERGIES

FAMILY HISTORY :

NO SIGNIFICANT FAMILY HISTORY

PHYSICAL EXAMINATION:

NO PALLOR , CYANOSIS , ICTERUS , CLUBBING , LYMPHADENOPATHY , OEDEMA ,

MALNUTRTION ,

VITALS :

TEMP - AFEBRILE

PR - 80BPM

RR - 26CPM

BP - 90/60 MMHG

SPO2 - 98%

GRBS - 109MG/DL

SYSTEMIC EXAMINATION :

CVS - NO MURMURS , NO THRILLS , S1 AND S2 HEARD

RR - NO DYSPNEA , WHEEZING , BREATH SOUNDS - VESICULAR , ADVENTITIOUS SOUNDS -

NO

ABDOMEN- SHAPE : SCAPHOID , NO TENDERNES , NO PALPABLE MASS , NORMAL HERNIAL

ORIFICES , NO FREE FLUID , NO BRUITS , LIVER AND SPLLEN NOT PALPABLE , BOWEL

SOUNDS - YES ,

CNS - NO FOCAL AND NEUROLOGICAL DEFICITS

Investigation

BLOOD UREA29-10-2023 12:22:PM92 mg/dl

42-12 mg/dl

SERUM CREATININE29-10-2023 12:22:PM4.7 mg/dl

1.1-0.6 mg/dl SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 29-10-2023

12:22:PMSODIUM135 mEq/L

145-136 mEq/L

POTASSIUM3.6 mEq/L

5.1-3.5 mEq/L

CHLORIDE101 mEq/L

98-107 mEq/L

CALCIUM IONIZED1.13 mmol/L

mmol/L

COMPLETE URINE EXAMINATION (CUE) 29-10-2023 03:47:PMCOLOUR

Pale yellow

APPEARANCE

Clear

REACTION

Acidic

SP.GRAVITY

1.010

ALBUMIN

++++

SUGAR

Nil

BILE SALTS

Nil

BILE PIGMENTS

Nil

PUS CELLS

2-4

EPITHELIAL CELLS

1-2

RED BLOOD CELLS

2-4

CRYSTALS

Nil

CASTS Nil

AMORPHOUS DEPOSITS

Absent

OTHERS

Nil

BLOOD UREA29-10-2023 03:47:PM93 mg/dl

42-12 mg/dl

SERUM CREATININE29-10-2023 03:47:PM4.7 mg/dl1.1-0.6 mg/dlSERUM ELECTROLYTES (Na, K,

C l) AND SERUM IONIZED CALCIUM 29-10-2023 03:47:PMSODIUM137 mEq/L

145-136 mEq/L

POTASSIUM3.6 mEq/L

5.1-3.5 mEq/L

CHLORIDE101 mEq/L

98-107 mEq/L

CALCIUM IONIZED1.01 mmol/L

mmol/L

LIVER FUNCTION TEST (LFT) 29-10-2023 03:47:PM

Total Bilurubin0.66 mg/dl

1-0 mg/dl

Direct Bilurubin0.17 mg/dl

0.2-0.0 mg/dl

SGOT(AST)25 IU/L

31-0 IU/L

SGPT(ALT)11 IU/L

34-0 IU/L

ALKALINE PHOSPHATE186 IU/L

141-53 IU/L

TOTAL PROTEINS4.8 gm/dl

8.3-6.4 gm/dl

ALBUMIN2.58 gm/dl

4.6-3.2 gm/dl

A/G RATIO1.16

Diagnosis SEPTIC SHOCK WITH AKI WITH LEFT LOWER LIMB DVT

Treatment Given(Enter only Generic Name)

IV FLUIDS NS,DNS @ 50ML/HR

INJ.METROGYL 500MG IV/TID

INJ.NORADRENALINE 4ML+46ML NS @ 4ML/HR INCREASE/DECREASE TO MAINTAIN

MAP>_65MMHG

INJ.PAN 40MG IV/OD

INJ.ZOFER 4MG IV/BD

INJ.PIPTAZ 4.5MG IV/STAT TO INJ.PIPTAZ 2.25MG IV/TID

NBM TILL FURTHER ORDERS

INJ.NEOMOL 1GM IV/SOS IF TEMP >_101F

MONITOT VITALS

INFORM SOS

Advice at Discharge

PATIENTS ATTENDANTS HAE BEEN EXPLAINED ABOUT THE CONDITION OF THE PATIENT

I.E, SEPTIC SHOCK WITH AKI WITH LEFT LOWE LIMB DVT AND THE NEED FOR FURTHER

HOSPITALIZATION AND TREATMENT BUT PATIENTS ATTENDANTS ARE NOT WILLING FOR

FURTHER HOSPITAL STAY. INSPITE OF EXPLAINING ALL COMPLICATIONS AND OUTCOMES

OF THE PATIENT FOR NOT RECIEVING THE TREATMENT PATIENTS ATTENDANTS ARE

WILLING TO TAKE THE PTIENT AND THE PATIENT HAS LEFT AGAINST MEDICAL ADVICE AND

WANTED TO GO TO ANOTHER HOSPITAL AS THEY STAY IN DIFFERENT CITY

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