50 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
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
67years/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
75 years/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 : 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:
NEGATIVELIVER 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.
