1 to 25 THESIS CASES
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
COLOURPale yellow
APPEARANCEClear
REACTIONAcidic
SP.GRAVITY1.010
ALBUMIN+
SUGARNil
BILE SALTSNil
BILE PIGMENTSNil
PUS CELLS3-4
EPITHELIAL CELLS2-3
RED BLOOD CELLSNil
CRYSTALSNil
CASTSNil
AMORPHOUS DEPOSITSAbsent
OTHERSNil
TROP I 62.6 MG /DL
HEMOGRAM
HAEMOGLOBIN 13.5 12.0 - 15.0
TOTAL COUNT 9900 cells/cumm 4000 - 10000
NEUTROPHILS 84 % 40 - 80
LYMPHOCYTES # 06% 20 - 40
EOSINOPHILS 01% 01 - 06
MONOCYTES 09% 02 - 10
BASOPHILS 00 % 0 - 2
PCV # 40.5 vol % 36 - 46
M C V 83.9 fl 83 - 101
M C H 28.2 pg 27 - 32
M C H C 33.4% 31.5 - 34.5
RDW-CV # 15.4 % 11.6 - 14.0
RDW-SD 47.9 fl 39.0-46.0
RBC COUNT 4.79 millions/cumm 3.8 - 4.8
PLATELET COUNT 1.51 lakhs/cu.mm 1.5-4.1
RBC NORMOCYTIC NORMOCHROMIC
WBC ADEQUATE
PLATELETS Adequate
HEMOPARASITES No hemoparasites seen
IMPRESSION microcytic hypochromic anemia with lymphocytosis
PERIPHERAL SMEAR 24-02-2024 05:58:PM
RBC : Microcytic hypochromic with pencil forms,teardrop cells seen
WBC : With in normal limits with Increased lympocytes decreased neutrophiles
PLATELET : Adequate
RETICULOCYTE COUNT-1.5%
RFT 8/3/2024
UREA 115 mg/dl 42-12 mg/dl
CREATININE 1.6 mg/dl 1.1-0.6 mg/dl
URIC ACID 9.2 mg/dl 6-2.6 mg/dl
CALCIUM 10.0 mg/dl 10.2-8.6 mg/dl
PHOSPHOROUS 3.9 mg/dl 4.5-2.5 mg/dl
SODIUM 140 mEq/L 145-136 mEq/L
POTASSIUM 3.2 mEq/L 5.1-3.5 mEq/L
CHLORIDE 99 mEq/L 98-107 mEq/L
RFT ON 9/3/24
UREA 117 mg/dl 42-12 mg/dl
CREATININE 1.7 mg/dl 1.1-0.6 mg/dl
URIC ACID 7.4 mg/dl 6-2.6 mg/dl
CALCIUM 9.4 mg/dl 10.2-8.6 mg/dl
PHOSPHOROUS 3.5 mg/dl 4.5-2.5 mg/dl
SODIUM 142 mEq/L 145-136 mEq/L
POTASSIUM 3.5 mEq/L 5.1-3.5 mEq/L
CHLORIDE 106 mEq/L 98-107 mEq/L
2D ECHO ON 4/3/24
RWMA +.RC AHYPO KINETIC
CAD WITH LCX AKINETIC TERRITORY
MODERATE TO SEVER MR +[NO MS ]
MR JET 9.91 CM2
MODERATE TO SEVER AR +;NO AS ANEURYSM
PHT =125 M/S
MODERATE TR POSITIVE WITH PAH [ECCENTRIC TR+]
EF=20 %;RVSP =42+10= 52 MM HG
SPECKS OF CALCIFIED TRILEAFLETS AV
MAC +;IAS INTACT
SEVERE LV DYSFUNCTION +;NO PE
GRADE 1 DIASTOLIC DYSFUNCTION +
NO PE
IVC SIZE 2.19 CMS,DILATED NON COLLAPSING
DILATED LA/LA/RA/IVC
MILD DILATED RV
REPAET 2D ECHO
MODERATE TR +;NO APH
IVC COLLAPSING
DILATED L.V/L.A
EF 17 %
USG ABDOMEN AND PELVIS
B/L GRADE II RPD
RIGHT RENAL CORTICAL CYST
Treatment Given(Enter only Generic Name)
1.FLUID RESTRICTION <2L / DAY
2.SALT RESTRICTION <2 GM /DAY
3.IVF 1. DNS @ 30 ML /HOUR
4.INJ LASIX 20 MG IV /TID
5.INJ HEPARIN 5000 IU /S.C /Q.I.D
6.TAB ECOSPORIN GOLD [75/75/20] P/O HG
8.TAB FEBUXOSTAT 40 MG PO/OD
9.TAB DIGOXIN 0.25 MG PO/OD
10.INJ DOBUTAMINE 2 AMP IN 45 ML NS @ 3 ML/HOUR [TAPERED ACCORDING TO M.A.P]
11.INJ NORAD 2 AMP IN 46 ML NS @ 3 ML/HR [TAPERED ACCORDING TO M.A.P]
Advice at Discharge
1.FLUID RESTRICTION <2L / DAY
2.SALT RESTRICTION <2 GM /DAY
4.TAB LASIX 20 MG PO /TID X 10 DAYS
5.TAB RIVOROXABAN 10MG PO/BD X 10 DAYS
6.TAB ECOSPORIN GOLD [75/75/20] P/O HS TO BE CONTINUED
8.TAB FEBUXOSTAT 40 MG PO/OD X 1 WEEK
9.TAB DIGOXIN 0.25 MG PO/OD X 10 DAYS
10.SYP MUCINAC GEL 15 ML IN 1 GALSS OF WATER PO/BD X 10 DAYS
Follow Up
REVIEW TO GM OPD AFTER 10 DAYS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed
and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been
explained to me in my own language
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:
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
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 : 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
RBC COUNT 3.73 MILLIONS/CUMM
PLATELET COUNT 1.20 LAKH/CUMM
SMEAR
RBC NORMOCYTIC NORMOCHROMIC
WBC INCREASED IN COUNTS ON SMEAR WITH NEUTROPHILA
PLATELETS INADEQUATE
HEMOPARASITES NOT SEENIMPRESSION NORMOCYTIC NORMOCHROMIC ANEMIA WITH
NEUTROHILIC LEUKOCYTOSIS AND THROMBOCYTOPENIA.USG ABDOMEN AND PELVIS ON
29/01/25:FINDINGS: E/O FREE FLUID IN B/L PLEURAL SPACEE/O MILD INTER BOWEL
FLUIDIMPRESSION: B/L PLEURAL EFFUSION2D-ECHO(BED SIDE) ON
28/01/25:TACHYCARDIARWMA ANTERIOR WALL AND APEX HYPOKINESIAMILD TR WITH
PAH(ECCENTRIC TR) RVSP2 38 + 05 = 43MMHGTRIVIAL AR/ MR; NO AS/MS; IAS-INTACTEF=
52% FAIR LV SYSTOLIC FUNCTIONNO DIASTOLIC DYSFUNCTIONNO PE; NO LV CLOTSIVC
SIZE (1.13CMS) COLLAPSING
Treatment Given(Enter only Generic Name)
1. RT FEEDS( 30ML WATER 2ND HRLY; 100ML MILK 4TH HRLY)
2. I.V FLUIDS NS AND DNS @50ML/HR
3. INJ. MEROPENEM 500MG PO/BD
4. INJ. CLINDAMYCIN 600MG IV/TID
5. INJ. PAN 40MG IV/OD
6. INJ. NORADRENALINE 2AMP(4ML-8MG) IN 46ML NS @ 21ML/HR
7. INJ. DOBUTAMINE 1AMP(5ML-250MG) IN 45ML NS @4ML/HR
8. INJ. VASOPRESSIN 2AM(2ML-40UNITS) IN 38ML NS @2.4ML/HR
9. NEBS (IPRAVENT 6TH HRLY; BUDECORT 8TH HRLY)
10. POSITION CHANGE 2ND HRLY
11. ET AND ORAL SUCTIONING 2ND HRLY
12. REGULAR MGSO4 DRESSING OF LEFT LOWER LIMB
13. LEFT LOWER LIMB ELEVATION
14. STRICT I/O CHARTING
15. MONITOR VITALS HOURLY
DEATH SUMMARY:
THIS IS A CASE OF 60YEAR OLD MALE RESIDENT OF SURYAPET, FARMER BY OCCUPATION,
KNOWN DIABETIC, CHRONIC SMOKER AND ALCHOLIC WAS BROUGHT TO CASUALTY ON
27/01/25 IN UNRESPONSIVE AND GASPING STATE GCS:E1V1M1(3/15) WITH H/OSWELLING
OF LEFT LOWER LIMB WITH BLEBS OVER LEFT LEG SINCE 7 DAYS, ASSOCIATED WITH HIGH
GRADE FEVER AND VOMITINGS AND GRADE 3 TO 4 BREATHLESSNESS. VITALS AT
PRESENTATION TEMP: AFEBRILE, PR: 48 BPM, SBP: 70MMHG(PALPATORY METHOD), RR:
18CYCLES PER MIN,SPO2: 88% AT 6 LIT OF O2,GRBS: 70MG/DL. ABG SHOWED TYPE-2
RESPIRATORY FAILURE. PATIENT WAS INTUBATE I/V/O TYPE-2 RESPIRATORY FAILURE AND
CONNECTED TO MECHANICAL VENTILATION . PATIENT HAD SUDDEN BRADYCARDIA WITH
CENTRAL PULSES, 5 CYCLES OF CPR WAS DONE AFTER WHICH ROSC WAS ACHIEVED.
IONOTROPIC SUPPORT WAS STARTED AS PATIENT HAD REFRACTORY HYPOTENSION
INSPITE OF FLUID RESUSCITATION. PATIENT HAD VT, DEFIBRILLATION WAS DONE WITH
200J FOLLLOWED BY DEFIBRILLATION WITH 360J AGFTER WHICH REVERTED TO AF.
PATIENT WAS SHIFTED TO ICU. TRIPLE LUMEN WAS PLACED AND STARTED ON TRIPLE
IONOTROPIC SUPPORT. SURGERY REFFERAL WAS TAKEN I/V/O LEFT LOWER LIMB
CELLULITIS, MGSO4 DRESSING WAS DONE AND STARTED ON ANTIBIOTICS AND OTHER
SUPPORTIVE TREATMENT. ALL APPROPRIATE INVESTIGATIONSWERE SNET. HEMOGRAM
SHOWED ELEVATED TOTAL WBC COUNTS WITH THROMBOCYTOPENIA AND RFT SHOWED
PRE RENAL AKI. ON DAY-3: SENSORIUM WAS IMPROVED AND OBEYING COMMANDS,
SHIFTED TO SIMV MODE. AFTER 6HRS PATIENT COULD NOT TOLERATE AND SHIFTED BACK
TO ACMV-VC MODE. ON 31/1/25 AT 7:40AM, PATIENT DEVELOPED ST-ELEVATIONS IN LEAD-2
IN ECG MONITOR, WITH NON-RECORDABLE BP, WITH ABSENT CENTRAL AND PERIPHERAL
PULSES, CPR WAS INITIATED ACCORDING TO LATEST ATLS GUIDELINES AND CONTINUED
FOR 30MIN. INSPITE OF ALL THE ABOVE RESUSCITATIVE EFFORTS, PATIENT COULD NOT
BE RECIEVED AND DECLARED DEATH ON 31/01/25 AT 8:20AM WITH ECG SHOWING
ISOELECTRIC LINE.
IMMEDIATE CAUSE OF DEATH: ACS - CAD - IWMI
ANTECEDENT CAUSE OF DEATH: 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, COPD, T2DM.
Death Date
Date: 31/01/25.
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.
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:
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
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
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.
