jankammma 73y female -202433096
73 YEAR OLD FEMALE RESIDENT OF NALGONDA WAS BROUGHT TO THE CASUALTY WITH
C/O SWELLING OF BOTH HANDS SINCE 4 DAYS
C/O DIFFICULTY SWALLOWING SINCE 1 DAY
HISTORY OF PRESENTING ILLNESS
PATIENT WAS APPARENTLY ASYPMTOMATIC UNTIL 4 DAYS AGO THEN HAD
C/O B/L UPPER AND LOWER LIMBS SWELLING INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE PITTING TYPE, AGGRAVATED ON WALKING; RELIEVED ON LOWER LIMB ELEVATION..
C/O DYSPHAGIA TO BOTH SOLIDS AND LIQUIDS SINCE 1 DAY.
NO C/O FEVER, COUGH, COLD, SOB
NO C/O ORTHOPNEA, PALPITATIONS, PND
NO CIO BURNING MICTURITION, INCREASED OR DECREASED URINE OUTPUT
NO C/O LOOSE STOOLS, NAUSEA, VOMITINGS, CONSTIPATION
PAST HISTORY:
K/C/O HTN SINCE 15 YEARS, STOPPED MEDICATION SINCE 15 DAYS
K/C/O CKD SINCE 15 YEARS
K/C/O CVA SINCE 2MONTHS, RIGHT HEMIPARESIS
K/C/O FLUOROSIS OF SPINE SINCE 13YEARS
H/O RIGHT LOWER LIMB FRACTURE SURGERY(TIBIAL PLATING )
PERSONAL HISTORY:
MIXED DIET
APPETITE NORMAL
BOWEL MOVEMENTS NORMAL
BLADDER: NORMAL
NO ALLERGIES
NO ADDICTIONS
FAMILY HISTORY NOT SIGNIFICANT
MENSTRUAL HISTORY: MENOPAUSE ATTAINED
GENERAL EXAMINATION:
TEMP: 98.6 F
PR: 110 BPM
BP: 130/80 MMHG
RR: 20 CPM
SPO2: 97%@RA
GRBS: 77 MG%
NO PALLOR, ICETRUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, SYSTEMIC EXAMINATION:
CVS: S1,S2 HEARD, NO MURMURS
P/A: DISTENDED, SOFT, NON TENDER, BOWEL SOUNDS HEARD
RS: BAE PRESENT, NVBS HEARD
CNS: CONSCIOUSNES:ALERT
SPEECH NORMAL
NECK STIFFNESS PRESENT
GLASCOW SCALE: E4V5M6
REFLEXES -
RIGHT LEFT
B3+ 3+
T2+ 3+
S2+ 3+
K+. +
A+. +
PLANTARS: FLEXOR EXTENSOR
SURGERY REFERRAL DONE ON 30/7/24 I/V/O BEDSORES.
ADVISED:
1. CST
2. FREQUENT POSITION CHANGE
3. ALPHA BED
4. FREQUENT PRESSURE DRESSING
5 AVOID SOILING
6. CHANGE OF DIAPER EVERY 6TH HOURLY
TOTAL 4 DIALYSIS DONE
1ST: 26/7/24
2ND: 28/7/24
3RD: 29/7/24
4TH: 31/7/24
2 BLOOD TRASFUSIONS DONE ON 28/7/24 AND 31/7/24
INVESTIGATIONS
25/07/2024. 27/07 ---28/07
HAEMOGLOBIN -7.2--- 6.4---7.9
TOTAL COUNT33,000-- 24,000-21,600
PLT 3.6----3.18---2.94
RETICULOCYTE COUNT - 0.5%
S.IRON -57UG/DL
BGT - AB NEGATIVE
ABG ON ADMISSION - PH -7.27
PC02 -21.9
P02-104
HCO3-9.9
25/07/24. 27/07 --29/07
RFT -UREA -244MG/DL ---- 117---103
CREAT -8.2MG/DL----5.1---3.9
NA+ 127--139--139
K+---7.0 ---5.2---4.0
CL-- 95 --102--101
30/07 ---1/08
HB-6.7---7.4
TLC -13,800--13,100
PLT -2.50----1.7
RFT -1/08
UREA -60
CREAT -2.4
NA -145
K-3.0
CL -102
FINAL DIAGNOSIS -ALTERED SENSORIUM SECONDARY TO UREMIC ENCEPHALOPATHY
SEPSIS SECONDARY TO UTI (RESOLVING)
AKI ON CKD (STAGE V) (RESOLVING)
K/C/O CVA SINCE 1/4MONTH (CHRONIC INFARCT IN LEFT TEMPOROPAREITAL LOBE AND MCA TERRITORY)
K/C/O HTN SINCE 15 YEARS
K/C/O CKD SINCE 15 YEARS
K/C/O FLUROSIS OF SPINE SINCE 13 YEARS
HFPEF
DE NOVO HYPOTHYROIDISM
GRADE II BEDSORES
TREATMENT GIVEN
1.RT FEEDS 100ML WATER 4TH HOURLY: 100ML MILK + PROTEIN POWDER 4TH HOURLY
2. INJ. LASIX 40MG IV/ BD (IF SBP >110 MMHG)
3. INJ. PIPTAZ 2.25 MG IV/TID
4. INJ. IRON SUCROSE 200ML IN 100ML NS IV (ALTERNATE DAY)
5. TAB. ECOSPRIN 25MG RT/OD
6. TAB. CLOPIDOGREL 25MG RT/OD
7. TAB. ATORVASTATIN 20 MG RT/HS
8. TAB. NODOSIS 500 MG RT/BD
9. TAB. OROFER XT RT/OD
10. TAB. SHELCAL-CT RT/OD
11. TAB. NICARDIA 10MG RTD
12. TAB. THYRONORM 25MCG RT/O/OD
13. INJ. EPO-4000 IU SC ONCE A WEEK
14. SYP. CITRALIKA 15ML IN HALF GLASS OF WATER
15. FLUID RESTRICTION
16. SALT RESTRICTION
17. AIR BED
18. FREQUENT POSITION CHANGE
19. DAILY DRESSING OF BED SORES
Advice at Discharge
1. FLUID RESTRICTION
2 SALT RESTRICTION
3. LASIX 40MG PO/BD
4. TAB. ECOSPRIN 5MG PO/OD
5. TAB. CLOPIDOGREL 75MG PO/OD
6. TAB. ATORVASTATIN 20 MG PO/HS
7. TAB NODOSIS 500 MG PO/BD
8. TAB. OROFER-XT PO/OD
9. TAR. SHELCAL-CT PO/OD
10. TAB. NICARDIA 10MG PO/OD
11. TAB. THYRONORM 25MCG PO/OD
12. INJ. EPO 4000 IU SC ONCE A WEEK
13. SYP. CITRALIKA 15ML IN HALF GLASS OF WATER TID
14. FREQUENT POSITION CHANGE
15. DAILY DRESSING OF BED SORES
16. POWDER NEOSPORIN FOR L/A
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