37 YEAR OLD MALE PRESENTED TO CASUALITY WITH SOB

 Case History and Clinical Findings

CHIEF COMPLAINTS

37 YEAR OLD MALE PRESENTED TO CASUALITY WITH SOB SINCE 19/5/2023 MORNING 10:00AM

HOPI:-

PATIENT WAS APPARENTLY ASYMPTOMATIC 4DAYS BACK AND AFTER FRESEHEN UP HE DRANK RAGIJAVA AND TOOK MEDICATION PRESCRIBED BY US DURING DISCHARGE THEN HE SUDDENLY STARTED HAVING SOB GRADE 4

PAST ILLNESS

F/U/C/O SEPSIS SECONDARY TO LEFT LOWERLIMB CELLULITIS (RESOLVED) HFMEF (EF 48%) WITH AKI ON CKD WITH ANEMIA (NC/NC) SECONDARY TO ?CKD WITH THROMBOCYTOPENIA WITHN K/C/O DM2 SINCE 12 YEARS AND K/C/O HTN SINCE 2 YEARS

S/P RAYS AMPUTATION OF GREAT TOE

S/P FASCIOTOMY LEFT FOOT 13/5/2023

3 SESSION OF HAEMODIALYSIS WERE DONE

PERSONAL HISTORY:

DIET-MIXED

APPETITE -NORMAL

BOWEL AND BLADDER - REGULAR

SLEEP-ADEQUATE

ADDICTIONS- NO

ALLERGIES- NONE

FAMILY HISTORY:

INSIGNIFICANT

GENERAL EXAMINATION:

PATIENT IS CONSIOUS ,COHERENT ,COPERATIVE

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY

VITALS:

TEMP-97.9F

BP- 120/80MMHG

PR-104BPM

RR-28CPM

SPO2-98% AT ROOM AIR

GRBS-580

SYSTEMIC EXAMINATION:

CVS-S1 S2 HEARD NO MURMURS

RS-BAE+ NVBS

P/A -SOFT NON TENDER,NO GUARDING,NO RIGIDITY, HERNIAL ORIFICES NORMAL


COURSE AT THE HOSPITAL:

PATEINT WAS ADMITTED I/V/O SOB GRADE 3 -4 INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE AND ON FURTHER EVALUATION,WAS FOUND TO HAVE HIGH SUGARS WITH GRBS 580 (URINE FOR KETONE BODIES- NEGETIVE) DUE TO NON COMPLIANCE TO MEDICATION WITH ABG SHOWING SEVERE METABOLIC ACIDOSIS ,INJ.NAHCO3 50MEQ IV STAT F/B 50MEQ IN 100ML NS. INJ.HAI 6U IV STAT GIVEN INFUSION 6ML/HR .INSULIN INFUSION GIVEN ACCORDING TO ALGORITHM 1 FOR 1 DAY LATER SHIFTED TO S/C INSULIN ACCORDING TO THE REQUIREMENT .TLC COUNT ELEVATED AND WAS STARTED ON INJ.PIPTAZ AND INJ METROGYL .SURGERY REFERAL WAS DONE ON 19/5/23 I/V/O LEFT LOWER LIMB S/P FASCIOTOMY ,SKIN OVER THE LEFT LIMB EDEMATOUS AND SHINY ERYTHEMA +,LOACL RISE OF TEMP+ EXTENDING TILL MID THIGH TO FOOT AND FASCIOTOMY INCISION PRESENT OVER MID THIGH,GRANULATION TISSUE PRESENT ,MINIMAL SLOUGH +,SEROUS DISCHARGE PRESENT FROM FASCIOTOMY SITE AND ADVICE FOLLWED AS PER ORDERDS AND REGULAR DRESSINGS WITH MGSO4 +GLYCERINE DRESSING DONE

ON DAY 2 PATEINT HAS LOOSE STOOLS (? ANTIBIOTICS INDUCED DIARRHEA AND ANTIBIOTICS STOPPED)

ON DAY3 ANTIBIOTICS STOPPED AND MANAGED CONSERVATIVELY ON 21/5/23 .PATIENT HAS BEEN TAKEN TO DIALYSIS 1ST SESSION WITH 2FFPS AND 1PRBC TRANSFUSION,(? UREMIC ENCEPHALOPATHY AND ANURIA)

PREVIOUS H/O SEPSIS SECONDARY TO LEFT LOWER LIMB CELLULITIS WITH HEART FAILURE WITH PRESERVED EJECTION FRACTION WITH AKI ON CKD WITH ANEMIA (NC/NC) WITH THROMBOCYTOPENIA

PATIENT WAS DISCHARGED WITH VITALS

TEMP-98.5

BP-140/70

PR 100BPM

RR-16CPM

SPO2-98%

GRBS -201 AT 8:00AM

PATIENT IS ADVISED FOR FOLLOWING I/V /O MAINTAINANCE OF HEMODIALYSIS


Provisional Diagnosis:-

UNCONTROLLED SUGEARS (? DIABETIC ACIDOSIS) LEFT LOWER LIMB CELLULITIS (RESOLVING) HEART FAILURE WITH PRESERVED EJECTION FRACTION WITH AKA ON CKD WITH ANEMIA (NC/NC) SECONDARY TO ? CKD WITH THROMBOCYTOPENIA 1 SESSION OF HEMODIALYSIS (2 FFPS AND 1 PRBC TRANSFUSION ) WITH K/C/O DM2SINCE 12 YEARS AND K/C/O HTN SINCE 2 YEARS

S/P RAYS AMPUTATION OF GREAT TOE

S/P FASCIOTOMY LEFT FOOT 13/5/2023


Investigation:-
19/5/2023 20/5/2023 21/5/2023 22/5/2023 23/5/23
HAEMOGRAM
HB-5.4 4.9 4.9 5.5 4.4
TLC-25000 12000 9400 9990 14770
RBC COUNT-1.90 1.75 1.71 1.86 1.51
PTL COUNT -50000 80000 50000 33000 35000
Treatment Given(Enter only Generic Name)
1.INJ.BICARBONATE 50MEQ IV STAT SLOW OVER 10MINS 50 MEQ IN 100ML NS OVER 30MINS
2.INJ. HAI 6U IV STAT F/B INFUSION @ 6ML/HR
3.IVF NS@ 75ML/HR
4.INJ.PANTOP 40MG 1V OD
5.INJ LASIX 20MG IV BD (SBP>110MMHG)
6.INJ.PIPTAZ 2.25GM IV /TID
7.INJ.METROGYL 500MG IV TID
8.TAB.NODOSIS 500MG PO/OD
9.INJ HAI 10U TID
INJ.NPH 8U BD
10.TAB SPOROLAC DS PO/BD
11.TAB OROFER XT PO/OD
12.INJ VANCOMYCIN 250MG IV BD
13.TAB RACECATODRIL100MG

Advice at Discharge
1.TAB PAN 40MG PO/OD
2.TAB LASIX 40MG PO/OD
3.TAB.NODOSIS 500MG PO/BD
4.TAB.OROFER XT PO/OD
5.TAB.SPOROLAC DS PO/TID
6.TAB RECECOTODRIL 100MG PO/TID

Follow Up:-
FOLLOW UP TO MEDICINE OP SOS

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