50yrs Female with Shortness of breath and vomitings

50years old female came to the casualty complaining of shortness of breath since one day. 

Patient was apparently asymptomatic two months back. She has an history of dog bite on right cheek for whick she was treated and follow all four doses of vaccines.

Two nights ago when she had developed headache which did not subside followed by and episode of vomiting yesterday after having breakfast which consisted of food particles. 

10 episodes of vomiting which mostly consisted of food particles.

In the afternoon she was unable to speak, she was able to understand the attender's speah but she could not answer.

Followed by shortness of breath gradually in onset, progressive in nature from grade 2 yesterday afternoon to grade 4 by tonight. 

She was taken to the local hospital and she was reffered here. 

She is not a known case of Diabetes mellitus, hypertension, bronchial asthma, tuberculosis, epilepsy. 

O/E- 

Pt was 

PR- 133

BP- unrecordable

RR-40

SpO2- 88

GRBS- 346

CVS- S1 S2 no murmurs

RS- trachea central

        Bilateral crepitations in infra mamillary and infra axillary regions 

Patient was intubated in view of falling saturations. 

3/10

4/10

ABG ON 3/10

Soap notes day 2

S - Pt on Mechanical ventilator. ACMV - VC MODE - TV -360ml

FI02-80%; RR -14/min; PEEP -5 com of h2o

Pt GCS-E1 Vt M4

Pt comatose and withdrawal present to deep painful stimulus. 2 episodes of ? GTCS. O

BP 90/60 mmhg on Nor ad 22ml/hr

Dobu -14 ml/hr

 RS BAE PRESENT.

CVS-S1S2 HEARD

PR-160 bpm, regular ( ecg showing svt sinus tachycardia) 

Tone increased

CNS - pupils - Dilated (secondary to

drugs)

Reflexes 

        B T S K A P

R. 2 2. 3 3 3 mute

L. 3 3 2 3 3 mute

A - Altered sensorium secondary to ? viral encephalitis (? rabies virus)

CARDIOGENIC shock secondary to hfref (? RECENT antero -septal wall MI)

? Viral pneumonia.

h/o dog bite 2 months ago. ? GTCS.

P-1) pt is on inotropes nor ad and dobutamine

2) RT FEEDS.

3) INJ PIPTAZ 4.5 G IV TID

4) IVF - NS/RL @ 30 ml/hr (slow iv) 5) TAB ECOSPRIN-AV (150/40mg )Od

6) Tab Clopitab 75 mg od 7) Tab pcm 650 mg RT sos

-Fundoscopy - normal

Plan for1) ct brain and lumbar puncture and send csf for rtpcr for rabdoviridae virus. 

2) repeat Bed side echo abg yesterday night :

 ph-7.27; pco2 45.6; po2- 125, so2-96; hco3- 20.6

S - Pt on Mechanical ventilator. ACMV - VC MODE - TV-360ml FIO2-60%; RR -14/min; PEEP -5 com of h2o Pt GCS-E1 Vt M1

A - Altered sensorium secondary to ? viral encephalitis (? rabies virus)

CARDIOGENIC shock secondary to hfref (? RECENT antero -septal wall MI)

? Viral pneumonia.

h/o dog bite 2 months ago. ? GTCS.

Pt blood pressure was low overnight inspite of increasing doses of nor adrenaline, dobutamine,vasopressin. Around 6 Am, in view of absent central pulse, cpr was started According to AHA guidelines and continued for 6 cycles. Inspite of above resucitative measures ,pt couldn't be revived and declared dead on 5/10/21 @ 6:42 AM.

IMMEDIATE CAUSE OF DEATH - Cardiogenic shock secondary to antero septal MI ANTECEDENT CAUSE OF DEATH - VIRAL ENCEPHALITIS (? rabies) ? Viral pneumonia. 

45 yrs old female, presented to casualty with complaints of Shortness of breath since 4 days. 

Patient was apparently alright 6 months back when sje had an episode of fever for 5days associated with vomiting for 2 days straight and was later bought to our hospital after series of investigations she was diagnosed with AKI 

Three months ago she had a wound over left ankle for which she taken. to a hospital and wound was dressed.

Since then patient has been on medication since 6 months after being diagnosed with chronic kidney disease and as rpd changes of grade 3

During regular check up in dec her creatinine was 4.8

she has no history of being diagnosed with HTN, DM, BA, TB, CVA Epilepsy

Past surgical history- 

History of hysterectomy 15yrs ago

 History of present admission- 

since 4 days patient expedian shortness of death which was aggravated at night while the second by the local medical practitioner she was told her blood pressure was elevated to 200/150 mm hg

she has reduced bowel movement since 2 days

she is complaining of body pains since 10 days

current treatment plan 

tablet lasix 40 MG

 tablet Met xl 50 mg

 tablet orofer xt po od

tab shelcal po od

tab nodosis 550mg po bd

60 old man farmer occupation from Nalgonda presented to the op complaining of lower back pain since a week, reduced appetite, facial puffiness and shortness of breath grade 3 since one week

20 years ago patient had an occupational accident where a bullock cart ran over his abdomen then underwent splenectomy and 4 prbc transfusion

2 years ago while farming he was wounded on the right dorsum of the foot which did not heal completely for nearly 2 years

on investigations low hemoglobin was found to be the main cause for his delayed wound healing and was referred to another Hospital,In Khammam, on further investigations – RFT, USG he was told to have a kidney infection due to SEPSIS from the ULCER.(?AKI due to SEPSIS) whete underwent 2 prbc transfusion prior operating at the wound site

October, 2021 – 

he was apparently alright when he developed-FEVER, COLD, PEDAL EDEMA (PITTING TYPE) , GENERALISED WEAKNESS OF THE BODY.

He was then taken to a hospital in Suryapet where he was diagnosed with chronic kidney disease and hypertension.

INVESTIGATIONS DONE- SERUM CREAT, CBP, USG ABDOMEN & PELVIS, CUE

Treatment given here – injection erythropoietin , tab.nodosis , tab.vitamin D3, tab.neurobion forte, tab.paracetamol

The symptoms subsided in 3 to 4 days. They continued the medication for one and half month and didn’t know whether to refill the medication or not.

DECEMBER,2021–

On 15/12/21 – after couple of days of stoppage of the medication that is a week back he developed – low backache, loss of appetite, SOB grade 3, facial puffiness, pedal edema (pitting type) which is when they presented to the OPD.

Addictions- chronic alcoholic since -40 yrs-90ml/day, chronic smoker since -40 yrs, 1 pack 20beedis/day, stopped 2 months back 

Diet- mixed

Bowel and bladder movements- regular , normal I/o 

Sleep-adequate

Appetite- reduced Pt is c/c/c.

Vitals- BP-150/100MM HG; PR-83BPM; RR-20CPM; TEMP-AFEBRILE

PALOR-PRESENT ;   ICTERUS-ABSENT         ; CLUBBING-ABSENT;    LYMPHADENOPATHY-ABSENT;   EDEMA-PRESENT 1 WEEK BACK, ABSENT NOW.

Pt is skinny and poorly nourished and has dry skin.

CVS- S1S2 HEARD, NO MURMURS, JVP-

RS-BAE+, NVBS +

CNS- NO FND, HMF INTACT

P/A- SOFT, NON-TENDER, BS +

Previous investigations

 ULTRASOUND WHOLE ABDOMEN

IMPRESSION:

*Bilateral Grade IV chronic renal parenchymal changes.

Current imaging and investigations-

 Diagnosis- Chronic kidney disease with hypertension

Treatment- 

 Tab.LASIX 4OMG TID

Tab.NODOSIS 550 MG OD

Tap.SHELCAL 500 MG OD

Tab OROFER-XT OD

Tab.NICARDIA 20MG BD

INJ.ERYTHROPOIETIN 4000 IU S/C

INJ.IRON SUCROSE 1AMP IN 100ML NS

FLUID RESTRICTION<1L/DAY

SALT RESTRICTION <2.4gm/day

Renal replacement therapt dialysis

57yr old male came to casualty complaining of shortness of breath since 10days, bilateral pedal edema since 6days, generalized itching ji ji since 6days, 

He was alright until 6 months ago when he noticed a small wound in his left leg. It was itchy around the site and he began to scratch the site constantly until it bled a month later. He complained of swelling and pain in his left leg as well due to which he was taken to local hospital. where he was diagnosed to have Thrombus in distal popliteal artery and told that he had Hypertension amd type 2 diabetes mellitus. 

he underwent Left Popliteal artery thrombectomy and his post operative period was uneventful. He took ecospirin and vit k antagonist for 15 days. 

he has been irregular with oral antiglycemics amd has not taken any medication for hypertension since then. 

he was told to have Bronchial asthma 3yrs ago following an episode of difficulty in breathing and used rotahaler he is 

currently he complaints of shortness of breath since 10days, bilateral pedal edema since 6days, generalized itching since 6days

personal history- he is married, has normal diet and appetite, reduced urination frequency and regular bowel habits 

does not have history of any substance abuse 

on examination- 

pt was C/C/C

Afebrile

BP- 150/100

PR- 90

RR- 20

SPO2- 94 % at RA 

CVS S1 S2+

RS- BAE+, NVBS 

PA- Soft, non tender

CNS- no FND 

Provisional diagnosis- chronic kidney disease with diabetic nephropathy stage 5 (7 ml per minute 1.73 m2) with metabolic acidosis a known case of diabetes since five months

plan of management 

salt restrictions less than 2.4 g per day 

fluid restriction less than 1 litre

 per day tablet lasix 40 mg p.o t.i.d 

tablet nodosis 55 mg

tab orofer XT PO OD 

tab shelcal 500 mg PO OD 

tab nicardia 10 mg PO OD

 injection erythropoietin 4000 IU s/c weekly once 

injection iron sucrose 1 ampule in hundred ml NS during dialysis

Impression from USG Doppler on 13th August 2021:

THROMBOTIC OCCLUSION OF CFA AND PROXIMAL SFA CASUING HEMODYNAMICALLY SIGNIFICANT CHANGES IN DISTAL BRANCHES > MONOPHASIC WAVE FORM IN EIA-TO R/O PROXIAML OCCLUSION

SOAP notes 

AMC cubicle 

subjective- patient has no fresh complaints objective- patient is c/c/c

BP- 140/80

PR 86bpm

CVS S1 S2 +

respiratory system- B/L creps present 

per abdomen soft and non tender

assessment CKD with diabetic nephropathy

(stage 5)

metabolic acidosis, k/c/o DM2

PLAN 

salt restriction less than 2.54 g per day 

fluid restriction less than 1 litre per day 

tab piptaz 4.5 gm BD

 tab levocetirizine 10 mg PO HS

tablet lasix 40 mg po/did 

tablet nodosis 550 MG PO bd 

tab orofer XT PO OD 

tab shelcal 500 mg PO OD 

tab nicardia 10 mg PO bd

 injection erythropoietin 4000 IU is s/c weekly once

 injection iron sucrose 1 ampule in hundred ml NS during dialysis

SOAP notes 

AMC cubicle 

subjective- patient has no fresh complaints objective- patient is c/c/c

BP- 140/80

PR 86bpm

CVS S1 S2 +

respiratory system- B/L creps present 

per abdomen soft and non tender

assessment CKD with diabetic nephropathy

(stage 5)

metabolic acidosis, k/c/o DM2

PLAN 

salt restriction less than 2.54 g per day 

fluid restriction less than 1 litre per day 

tab piptaz 4.5 gm BD

tab levocetirizine 10 mg PO HS

tablet lasix 40 mg po/did 

tablet nodosis 550 MG PO bd 

tab orofer XT PO OD 

tab shelcal 500 mg PO OD 

tab nicardia 10 mg PO bd

Inj. erythropoietin 4000 IU is s/c weekly once

Inj. iron sucrose 1 ampule in hundred ml NS during dialysis

Syp Aristozyme 

Soap notes 

AMC cubicle 

subjective patient has more fresh complaints

objective 

patient is C/C/C 

blood pressure 150/ 90 

PR 100 BPM 

CVS S1 S2 present 

RS BAE present

assessment CKD diabetic nephropathy stage 5 with metabolic acidosis known case of diabetes mellitus since 2 months

plan

 fluid restriction less than 1 litre per day salt restriction less than 2.4 g per day 

tab lasix 40 mg PO bid 

tab nodosis 500 mg PO bid 

tab orofer XT pure OD 

tab shelcal CT 500 mg OD 

tab nicardia 10 mg BD 

injection piptaz 4.5 g IV BD 

injection albumin 20% lv

tab levocetirizine OD HS

 injection erythropoietin 4000 IU sc

Soap notes 

AMC cubicle 

SUBJECTIVE 

patient has no fresh complaints

OBJECTIVE 

patient is C/C/C 

blood pressure 150/ 90 

PR 100 BPM 

CVS S1 S2 present 

RS BAE present

ASSESSMENT CKD diabetic nephropathy stage 5 with metabolic acidosis known case of diabetes mellitus since 2 months

PLAN

 fluid restriction less than 1 litre per day salt restriction less than 2.4 g per day 

tab lasix 40 mg PO bid 

tab nodosis 500 mg PO bid 

tab orofer XT pure OD 

tab shelcal CT 500 mg OD 

tab nicardia 10 mg BD 

injection piptaz 4.5 g IV BD 

injection albumin 20% lv

tab levocetirizine OD HS

 injection erythropoietin 4000 IU sc

calamite lotion 

candid cream LA

liquid paraffin 

55yrs old male with history of Seizures

55 year old male was bought to the casualty with complaints of 2 episodes of seizures 

Patient was apparently asymptommatic 6 months ago

History of CVA- left sided hemiplegia with deviation of mouth on the right side

2 months ago history of intake of oral hypoglycemic agents with no intake of food after which patient developed altered sensorium for which he was adnitted in our hospital and was diagnosed with medication induced hypoglycemia

At around 7: 30 am today while patient's attender  was giving a bath to the patient, he had tonic posturing of right upper limb with uprolling of eyeballs, frothing+ and patient became alright after 10 minutes

At around 1pm patient had similar episode when he was sleeping on bed and was immediately brought here 

No history of fever, vomitings, headache 

Patient is a known hypertensive on TAB. TELMA 40 MG OD

Known diabetic on TAB. METFORMIN 500 MG BD

History of CVA on TAB. ECOSPIRIN 

Patient has a lesion over his right buttock since 1yr uses an (?)ointment  local application.

Patient takes mixed diet, appetite normal, sleep adequate, bowel and bladder habits regular 

Vitals at the time of admission:

Temp: afebrile

PR: 110 bpm

BP: 160/100 mm hg

RR: 18cpm

Spo2: 98% at room air

GRBS: 107 mg/ dl 

CVS: S1S2+

RS: BEA+, NVBS+

P/ A: SOFT, NON TENDER

CNS:

Deviation of mouth to right

Speech- irrelavant

Cranial nerves-

Motor system 

Power

                UL                  LL

    Right.   5/5                5/5

    Left.      0/5.               0/5

Tone- B/L UL- increased

Reflexes B T. S K A plantar- 

             L 3+ 3+ 3+ +3 -. flexed 

            R - 1+ 3 +2 +2. - extensor

Gait- could not examine 

D- seizures under evaluation with post ictal confusion with left hemiplegia

With diabetes and hypertension 

Treatment:

INJ. LEVIPIL 1GM IV STAT 

INJ LEVIPIL 500 MG IV BD

INJ LORAZ 2CC IF SEIZURES+

TAB. TELMA 40 MG PO OD

INJ HAI ACC TO GRBS

RT FEEDS MILK WITH PROTEIN POWDER TID

BP/ PR CHARTING 2ND HOURLY

GRBS MONITORING 6TH HOURLY

W/F SEIZURE ACTIVITY

Soap notes 

No seizure episodes

Lethargic No fever spikes

0

Drowsy but arousable

BP:120/90 mmHg

PR:112 bpm

TEMP:98° f 

CVS:S1 S2 HEARD 

CNS: deviation of mouth to right

GRBS:106 mg/dl 

RS:BAE + ,NVBS

Tone: R.     L

UL      N   Increased

LL      N Increased

Power:

        R     L

UL  5/5  0/5

LL 5/5 0/5

Reflexes:BTSKA P

Right.      1+ 1+ 1+ 3+ 1+ flex

 Left        3+3+ 2+ 3+ 1+ ext

A

SEIZURES UNDER EVALUATION WITH POST ICTAL CONFUSION

DM +

HTN +

H/O CVA left sided

P

INJ.Levipil 500 mg iv bd

Inj.Loraz 2 cc iv sos

Inj Pantop 40 mg iv od

GRBS 6th hrly (8am 2pm 8pm 2am)

Inj H Actrapid acc to GRBS

Watch for seizure activity 

RT feeds milk 200ml RT TID

free water 100 ml 2nd hrly 

BP/ PR charting 2nd hrly