Medicine Department : 50 deidentified Case report forms of the Narketpally altered sensorium outcomes project

Project problem statement and summary protocol as well as initial thematic analysis are available in the previous archive here: https://medicinedepartment.blogspot.com/2024/06/altered-sensorium-outcomes-projr-case.html?m=1

Case 1:

ALTERED SENSORIUM SECONDARY TO HYPOGLYCEMIA (RECOVERED) HYPONATREMIA Case History and Clinical Findings Altered behaviour since 1 hr Difficulty in swallowing since 4 days 65 year old female patient non diabetic non hypertensive who is a Telugu tutor at home and was able to do all her house hold works on her own till 2006 then from 2006 she was getting water from step well then she got her hipand knee pains from 2008 where they took to hospital they suggested for surgery but Attendors neglected it because of financial issues then from that time patient was slowly walking from 1 year she started walking with the support(wall) and do her own works then from few days she is walking with walker . Patient had odynophagia since 4 days then she did not take food and on the day of admission she got up in the mrng and was oriented to place time and person then after some time she was not oriented to person since afternoon then they brought patient to the hospital with complaints of Altered behaviour since1 hr ,Difficulty in swallowing since 4 days Past history : N/K/C/O DM ,HTN, CAD ,Asthma, TB ,seizures O/E : NO Pallor, icterus, cyanosis,clubbing,lymphadenopathy,Edema pt is c/c/c Afebrile PR: 98bpm BP:110/70mmHg RR: 18cpm CVS: S1S2+ RS:BAE+ CNS: Handedness: right handed Consciousness: conscious GCS: E4V5M6 Orientation: oriented to place time and person,Memory: Immediate: intact Recent: intact Remote:intact Attention: intact Calculation: intact Cranialnerves: normal Motor system Attitude - lower limbs flexed at knee joint Muscle tone: Right. Left UL N. N LL. N. N Muscle power: UL. 5/5. 5/5 LL 4/5 4/5 Reflexes Right Left Biceps 2+ 2+ Triceps 2+ 2+ Supinator 2+ 2+ Knee - Ankle - Page-3 Platar. Mute Extends

Superficial reflexes and deep reflexes are present , normal Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are normal BRIEF COURSE IN HOSPITAL: patient came to opd with the c/o: Altered behaviour since1 hr Difficulty in swallowing since 4 days pt presented with altered behaviour i.e not oriented to place and person due to hypoglycemia (50mg/dl)then 25D was connected where patient grbs levels got increased to 138 from thn patient got oriented to place and person then patient complained of blurring of vision for which ophthamology refferal was taken ophthamology referral: fundocsopy was done impression:no abnormalities in fundal examination noted orthopaedics referral: orthopaedics referral was taken i/v/o: since hass difficulty in walkingsince 2008 and had fixed joints since 5 years L/E: patient is lying in supine position with both hips and knee in flexed position knee right left skin norml niormal swelling (-) (-) local rise of temp (-) (-) crepitus (+) (+) tenderness medial and lateral mediual and lateral joint lines both medial joint line and lateral femoral condyles rom fixed in flexion of 60 deg fixed in flexion 60 degree further flexion of 15degree further flexion of 15deg present and painful present and painful extension absent absent

ankle movements (+) (+) toe movements (+) (+) sensations (+) (+) distal pulses (+) (+) DIAGNOSIS:GRADE C4 OA B/L KNEE WITH LEFT PROTRUSSION ACETABULI adviced to phsiotherapy ENT REFERRAL: ent referral was taken for dysphagia and adviced for upper GI endoscopy Treatment Given(Enter only Generic Name) 1. PLENTY OF ORAL FLUIDS 2.SYP. POTKLOR 15ML PO/TID 3.BP MONITORING 4TH HRLY 4.GRBS MONITORING 5.INFORM SOS

Outcome: patient improved clinically,after correction of her hyponatremia.

GOOD RECOVERY ..

Case 2:

61,M

ALTERED SENSORIUM SECONDARY TO HYPONATREMIA EUVOLEMIC ? SIADH ? WITH HYPOKELEMIA WITH SMALL HEMORRHAGIC CONTUSION FRONTAL LOBE WITH AKI ( RESLOVING ) WITH HYPERTENSION SINCE 4 YEARS,WITH TYPE 2 DIABETES SINCE 18 YEARS Case History and Clinical Findings A 60 YEAR OLD MALE WAS BROUGHT TO CASUALITY IN ALTERED SENSORIUM SINCE YESTERDAY NIGHT PATIENT WAS APPARENTLY ASYMPTOMATIC 10YEARS BACK THEN HE DEVELOPED DM-2 SIMILAR EPISODE THEN HE DIAGNOSED TO HAVE DM-2 AND STARTED ON OHA LATER AFTER FEW YEARS PATIENT WAS SHIFTED TO INSULIN 4YEARS BACK PATIENT DEVELOPED GIDDINESS AND WHILE WORKING PT HAF FALL, FRACTURE RT UL &RT LL, DIAGNOSED WITH HTN ( ON TAB.METOSARTAN CH50, METOPROLOL 50, TELMA 40 ) 2 YEARS BACK PT DEVELOPED SIMILAR COMPLAINTS OF ALTERED SENSORIUM AND WAS HAVING HYPERGLYCEMIA AT PRIVATE HSPTL THEN WAS DIAGNOSED TO HAVE ? DKA ; -GIVEN INSULIN AND TREATED,AFTER THAT;10 DAYS BACK PATIENT DEVELOPED SWELLING OF LOWER LIMBS AND ULCERATION ON RT TOE AND PLANTAR ASPECT OF FOOT FOR WHICH HE WENT TO PUT PRACTITIONER AND DIAGNOSED TO HAVE DIABETIC FOOT AND WAS TREATED WITH REGULAR DRESSINGS AND ANTIBIOTICS LATER 4 DAYS BACK PATIENT DEVELOPED NAUSEA , VOMITING - 2 EPISODES / DAY ASSOCIATED WITH FOOD INTAKE. FOOD PARTICLES AS CONTENT, NOT BLOOD TINGED, 10 MINS AFTER FOOD INTAKE NO H/O FEVER,COLD, COUGH, PAIN ABDOMEN, LOOSE STOOLS, BODY PAINS NOT A K/C/O ASTHMA,CAS,TB,EPILEPSY,CVA O/E : PT IS CONSCIOUS, COHERENT, COOPERATIVE NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LY,PHEDENOPATHY, EDEMA TEMP: 98.9 F PR: 86/MIN BP: 130/80 MM HG CVS : S1, S2 +, NO ADDED SOUNDS JVP NOT RAISED RS : BAE + , NVBS P/A : SOFT, NT, BS + CNS : GCS - E4 V5 M6 NO MENINGIAL SIGNS HMF INTACT POWER : RT - UL : 5/5, LL : 5/5 LT - UL : 5/5, LL : 5/5 TONE : RT - UL : N, LL : N LT - UL : N, LL : N REFLEXES : B T S K A PLANTAR RT : + + + + + FLEXION LT : + + + + + FLEXION,Course in the hospitalThe patient got admitted with above mentioned complaints. At the time of admission the patient is drowsy arousable to deep pain not oriented to time place and person patient in altered sensorium on investigating found to have serum osmolality-258 Na-108 and K-2.1 was treated with 3%Ns ,the next day the patient is conscious and still drowsy with Na-115 k-2.2 sr.creat1.9. Diagnosed as altered sensorium with hypotonic hyponatremia euvolemic ?siadh with small hemorrhagic confusion in frontal lobe. Urine osmolality -107mosm Na-123 K-2.8 cr-1.9 urea-70 patient is conscious. Na-130 k-3.1 urea-48 creat-1.7 patient is conscious coherent and cooperative ABGpH 7.53Pco2-27.8Po2-6.50Hco3-23.6Urinary Na- 155K-19.3Cl-122 Volume 1900UNa-213Uk-12.9Ucl- 220Creat-0.40Protein-774Ca2+-58Uric acid-570Referred to General surgery in view of right diabetic toe. Lateral debridement and cuticle dressing with antiseptic dressing is doneMRI BRAIN- small hemorrhagic contusion in right frontal lobeReferred to neurosurgery In view of small hemorrhagic contusion in right frontal lobe and was suggested to continue same treatment Referred to ophthalmologist in view of increased ICT features. Fundus showed no raised ICT features Investigation HEMOGRAM HB-11.1 TLC-16800 PLT-2.0 PCV-28.5 MCH-28.7 MCHC-38.9 MCV-73.6 RBC-3.87 25/12/2022 HB-11.3 TLC-12,300 PLT-2.0 PCV-28.9 MCH-29.4 MCHC-39.1 MCV-75.3 RBC-3.8,26/12/2022 HB-10.7 TLC-13000 PLT-2.39 RBC-3.68 USG ABDOMEN : RIGHT SIMPLE RENAL CORTICAL CYSTS MRI BRAIN PLAIN : SMALL HEMORRHAGIC CONTUSION IN RIGHT FRONTAL LOBE 2D ECHO REPORT : NO RWMA, CONCENTRIC LVH + ( 1.30 CMS ) TRIVIAL TR +/ AR + ; NO MR SCLEROTIC AV , NO AS/MS , IAS - INTACT EF = 60, RVSP = 35 MM HG GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION + , NO PE IVC SIZE ( 1.39 CMS ) Treatment Given(Enter only Generic Name) IVF - 3 % NS @ 20ML/HR INJ. ZOFER 4 MG/IV/TID INJ.KCL 1 AMP + 100 ML NS SLOWLY OVER 2-3 HRS INJ.HAI S/C TID ACC TO SLIDING SCALE INJ. MONOCEF 2G/IV/BD INJ. PAN 40 MG IV/OD RT FEEDS 100 ML WATER HRLY& 100 ML MILK 2ND HRLY &COCONUT WATER 50 ML/BD SYP.POTCHLOR 15 ML PO/TID INJ. PAN 40 MG /IV/OD TAB. ALDACTONE 25 MG/PO/BD TAB.NICARDIA 10 MG PO/STAT TAB. TOLVAPTAN 15 MG/PO/OD,

STRICT HRLY URINE OUTPUT MONITORING TAB.TELMA 40 MG PO/BD TAB.MET XL 25 MG PO/BD Advice at Discharge TAB.MERTFORMIN 500MG PO/BD TAB.GLIMIPERIDE 1MG PO/BD TAB.TELMA 40 MG PO/BD TAB.MET XL 25 MG PO/BD SYP.CREMAFFIN 20ML PO/HS Follow Up REVIEW TO MEDICAL OPD ON FRIDAY / SOS..

*Outcome:GOOD RECOVERY*

Case 3:

51,F

1 DENGUE HEMORRHAGIC FEVER OR EXPANDED DENGUE FEVER WITH POLYSEROSITIS ( RESOLVED ) 2 ALTERED SENSORIUM (RESOLVED ) SECONDARY TO ? DENGUE ENCEPHALITIS /HEPATIC/UREMIC ENCEPHALOPATHY 3 PRE RENAL AKI(RESOLEVD) 4 ACUTE LIVER INJURY 6 GRADE II BEDSORES 7 KNOWN CASE OF TYPE 2 DM Case History and Clinical Findings CHIEF COMPLAINTS : C/O DRY COUGH SINCE 7 DAYS C/O SOB SINCE 4 DAYS C/O ABDOMINAL DISTENSION SINCE 4 DAYS C/O DECRAESED URINE OUT PUT SINCE 4 DAYS HOPI:PATIENT WAS APPARENTLY ALRIGHT 7 DAYS BACK THEN SHE DEVELOPED FEVER ASSOCIATED WITH CHILLS AINSIDIOUS IN ONSET NOT ASSOCIATED WITH MYALGIA OR ARTHRALGIA H/O DRY COUGH SINCE 7 DAYS , NO SEASONAL VARIATION OR DIURNAL VARIATION, NOT ASSOCIATED WITH BLOOD,FEVER ASSOCIATED WITH DECREASE IN APPETITE ON DAY 1 OF ILLNESS SHE SOUGHT CONSULTATION FOR RMP AND WAS TAKING TREATMENT ON DAY3 OF ILLNESS SHE WAS HAVING SOB GRADUALLY PROGRESSIVE FROM GRADE 1 TO 5 ON NYHA H/O ABDOMINAL DISTENSION SINCE 4 DAYS GRADUALLY PROGRESIVE TO PRESENT SIZE ASSOCIATED WITH ABDOMINAL PAIN H/O DECRESED URINARY OUT PUT SINCE 4 DAYS NO HEMATURIA, BLOOD IN STOOLS, OR OTHER BLEEDING MANIFESTATIONS COMPLAINTS PAST HISTORY : K/C/O DM SINCE 1 YEAR NOT A K/C/O DM, TB, ASTHMA, TB, EPILEPSY, HYPERTENSION PERSONAL HISTORY : APPETITE : NORMAL DIET : MIXED BOWEL AND BLADDER : REGULAR SLEEP : ADEQUATE ADDICTIONS : OCCASIONAL ALCOHOLIC AND TODDY DRINKER MENSTRUAL HISTORY : AGE OF MENARCHE : 13 YEARS CYCLES : REGULAR ATTAINED MENOPAUSE OBSTRETRIC HISTORY : NULLIPAROUS GENERAL EXAMINATION : PATIENT WAS CONSCIOUS , COHERENT COOPERATIVE PETECHIAE PRESENT VITALS : TEMP : AFEBRILE BP :130/80 MMHG HR : 78BPM SPO2 : 98% ON RA

GRBS : 142 MG/DL SYSTEMIC EXAMINATION: CNS : GCS : E4V5M6 PATIENT WAS CONSCIOUS , ORIENTED TONE AND POWER NORMAL IN ALL LIMBS REFLEXES : B T S K A P RT ++ ++ + + ++ F LT ++ ++ + ++ ++F CRANIAL NERVES INTACT CVS : S1, S2 HEARED NO MURMURS RS : BAE + , CLEAR P/A : SOFT NONTENDER , BS :+ BRIEF COURSE IN HOSPITAL :57 YEAR OLD WOMEN WHO PRESENTEDTO THE CASUALTY WITH DENGUE FEVER WITH THROMBOCYTOPENIA IN A TACHYPNOEIC STATE AND WITH PETECHIAE. SHE HAD INTACT SENSORIUM ON DAY 1, ON FURTHER EVALUATION SHE WAS FOUND TO HAVE PRE RENAL ACUTE KIDNEY INJURY ALONG WITH LIVER INJURY. ON DAY 2, SHE WENT INTO ALTEREDSENSORIUM WITH HYPONATREMIA OF AROUND 122 MG/DLOF SERUM SODIUM,3% NACL WAS GIVEN, EVEN POST SODIUM CORRECTION HER SENSORIUM HASNT IMPROVED . CT BRAIN WAS DONE TO RULE OUT BLEED WHICH WAS ABSENT . EVEN FUNDOSCOPY WAS DONE TO RULE OUT RAISED ICT . DAY 3: HER ALTEREDSENSORIUM WAS SECONDARY TO ? DENGUE ENCEPHALITIS ? HEPATIC ENCEPHALOPATHY ? UREMIC ENCEPHALOPATHY INJ DEXA 8 MG WAS GIVEN I/V/O CONTINUOUS FEVERSPIKES INJ ARTESUNATE WAS STARTED ON DAY 3 . HER UREMIA AS WELL AS HEPATIC ENZYMES ARE CONSTANTLY RISING WE TOOK HER TO 2 SESSIONS OF HEMODIALYSIS ON 29, 30 TH DECEMBER 3RD HEMODIALYSIS SESSION DONE ON 2ND JANUARY N ACETYLCYSTEINE WAS STARTED FOR 3DAY SON I/V/O ACUTE LIVER INJURY AND PERSISTANTLY HIGH BILIRUIN LEVELS PATIENT SENSORIUM IMPROVED ON 1ST JANUARY. GASTRO OPINION WAS TAKEN. HE ADVISED TEST FOR ANTIBODIES HEPATITIS A AND E AND ASKED REVIEW WITH LFT REPORTS.

ON 9 TH JAN HER HEMOGRAM WAS SHOWING HB :10, TLC :8,900, PC : 1.65 LAKH ,PT :20SEC,INR : 1.48 ,APTT : 39 SEC PATIENT WAS DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION. Investigation USG ABDOMEN : NO SONOLOGICAL ABNORMALITY DETECTED 2D ECHO EF : 60% NO RWMA TRIVIAL TR/MR SCLEROTIC AV, NO AS/MS 2D ECHO :IVC SIZE : 1.10 CMS GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION,NO PAH/PE REVIEW ECHO 0N 2/123 IVC COLLAPSING: 1.38 CMS MALARIAL PARASITE NEGATIVE,RT-PCR NEGATIVE BLOOD AND URINE CULTURE SENSITIVITY : NO GROWTH DETECTED AFTER 48 HOURS OF INCUBATION Treatment Given(Enter only Generic Name) IV FLUIDS @ 100ML/HR INJ PIPTAZ 2.25 GM /IV/TIDINJ VIT K 1 AMPOULE IN 100ML NS IV /OD TAB DOXYCYCLINE 100MG /PO/BD INJ OPTINEURON 1 AMPOULE IN 100 ML NS IV /OD SYP POTCHLOR 10 ML/TID INJ HUMAN ACTRAPID INSULIN /SC/ TID 4U-4U-4U DRINK PLENTY OF ORAL FLUIDS DAILY BEDSORE DRESSING 3 HEMODIALYSIS SESSIONS DONE Advice at Discharge 1.INJ. HUMAN ACTRAPID INSULIN SUBCUTANEOUS THRICE A DAY 8AM--2PM--8PM 4U--4U--4U Page-4 2.TAB.RIFAGUT 550MG ORALLY TWICE A DAY 7AM-9PM FOR 7DAYS

3.TAB.PAN 40MG ORALLY ONCE A DAY AT 7AM BEFORE BREAKFAST FOR 5DAYS 4.SYP HEPAMERZ 15ML ORALLY THRICE A DAY 8AM-2PM-8PM FOR 15DAYS 5.SYP POTKLOR 10ML ORALLY THRICE A DAY 8AM-2PM-8PM 6.SYP LACTULOSE 10ML ORALLY TWICE A DAY 8AM-9PM FOR 7 DAYS 7.CREAM ZINC OXIDE FOR LOCAL APPLICATION 8. WATCH FOR HYPOGLYCEMIC SYMPTOMS [EXPLAINED TO PATIENT]

*Patient outcome:

GOOD RECOVERY*

Case 4:

41,F

Diagnosis 1. Hypoxic Ischemic Encephalopathy (post CPR status) 2. Generalised Status Epilepticus secondary to autoimmune vasculitis - PRES/Septic/ Uremic Encephalopathy 3. Prerenal AKIon CKD on Hemodialysis 4. Urinary tract infection 5. Antisynthetase syndrome 6. Pulmonary TB 7. ? Invasive Aspergillosis 8. Post Tracheostomy 9. Grade 3 bedsore Case History and Clinical Findings.

Cheif complaints :- Patient was brought with complaints of 2 episodes of involuntary movements of upper and lower limbs and hemoptysis .History of present illness :- Patient was apparently asymptomatic till 5 am then she developed sudden onset of movements of both upper and lower limbs at 5am in the morning which lasted for about 4-5mins , not associated with any trigger, no aura and the patient was confused after the episode she had an other similar episode while bringing to the hospital.She had two similar episodes at the hospital.Sequence of events :- 13 years ago she developed low back ache and generalised weakness started for which she went to local hospital.Then during the investigations was found to be having soft tissue overgrowth,(as said by attenders ,no documentation)and need to get operated, during routine investigations creatinine was elevated, then she was started on conservative management .(Sod bicarb,Shelcal,Omeprazole,Iron folate)Since then ,she is on routine followup with hemogram and serum creatinine levels,and her baseline creatinine levels were 3.2mg/dL.In june 2022,she developed fever and productive cough associated with SOB for which CT chest was done,showing peripheral ground glass opacities,and septal thickening was notedand few days later , she developed swelling of both lower limbs till the level of ankles,which were insidious in onset and gradually progressiveThen underwent dialysis for the first time through right IJV line,for 4 hours,and was on conservative management.3 months later, she developed fluid filled bleb, on one finger and then over all the 10 fingers of hand in 10 days ,some of which ruptured on their own and some were pricked by the patient.She developed eroding nails and distorted nails , hyperpigmented macules over the face and itching over the palms,and low grade fever associated with loss of apetite and alopecia.Ulcers over palms , pulp of fingers associated with burning sensation With autoimmune etiology suspicion, she was investigated further and was ANA profile and was tested Positive for Anti Ro 52and SSA/Ro 60++,and SSB/La+.2days back she developed sudden onset developed movements of UL and lowerlimbs, for 3-4minutess, associated with blood from mouth,and there is a brief period of LOC .similar episode one at 6:00 am, and then 2 similar episodes after they came here at 8:00am.At presentation her blood pressure was 170/110MMHGCourse in hospital:- 46years old female came with complaints of Hemoptysis and involuntary moments of upperlimb and lowerlimb 4 episodes since morning, and her GCS at presentation being E1v1m1,pupillary reflex and corneal reflex was present,At presentation her blood pressure was 170/110 mmhg ,inj lorazepam was given, later leviteracetam was given and when her seizures weren’t controlled then sodium valproate was given She later then had continuous episodes of seizures lasting for more than 45 minutes . In view of respiratory distress ( sats 60 ),and uncontrollable recurrent seizures she was sedated with IV MIDAZOLAM and intubated. Post intubation, she had cardiac arrest ( no central pulses palpable ) 2 cycles of CPR done ROSC was achieved and post CPR monitor showed monomorphic VT and 2 times 200 J of DC shock was given and then it reverted to sinus tachycardia. Course in hospital :After returning to normal rythm Post cpr day 1 :- pt is on mechanical ventilator ACMV/VC mode with fio2 of 40 per peep :- 5 cms h20 tidal volume -450ml and t inspiratory -1.5 and started on iv antibiotics and patient is on sedation with midazolam cont iv infusion and her pupils are dilated and non reactive to light with dolls eye reflex: eyes moving on same side And mri brain was done and it showed -? PRESS ? ODS ?uremic encephalopathy Upper limb reflexes are present on left side and lower limb reflexes are absent and plantars are mute and derma referal was taken for the blebs over hand and was diagnosed as ?bullous phemphigoid ? Friction induced blisters and ophthalmology opinion was taken to rule out rasied icp but no raised ict features are seen on fundoscopy and nephrology opinion was taken i/v/o raised renal parameters and they advised for hemodyalsis and one session was done on 5/1/23 on next day midazolam infusion was stopped to plan for extubation but as patient is not taking breaths spontaneously extubation was not done and i/v/o raised pt aptt inr vit k was given and neurology opinion was taken and they advised for EEG and lumbar puncture was done and pulmonolgy opinion was taken for resuming ATT and advise followed and on D3 of intubation patient is on ACMV/Vc mode with rr :- 14cpm fio2 :-45 peep :- 5 VT :- 450ml tinsp :- 1.9 and she developed ulceration over the sacral region ? Bed sore and surgery opinion was taken and was diagnosed as having a soft tissue based non mobile and non blanchable ulcer with partial thickness skin loss and late superficial ulcer ? Grade 2 bed sore and reflexes of b/l UL and LL were absent and pupils decreased in size and reacting to lights and dolls eye moving to same side and GCS :- E1VTM1 and antifungal tab voricanzole was started (as BAL showed aspergillosis ) on day 4 of intubation pt was taken for second session of hemodialysis on 8/1/23 and anesthesia opinion was taken for weaning of from ventulator but as the weaning of criteria was not met and as patient is tachypnic patient is restarted on midazolam 30mg and fentanyl 200mcg as per anesthetist advise and patient is shifted to SIMV mode on day 5 of intubation sedation was stopped at 8:00 am as patient is taking spontaneous breaths and inview of deranged Pt,APTT and INR,4 FFP transfusions were done,and as the patient blood pressure is persistently high,she was started on calcium channel blocker(Tab.Amlong 10mg), and as the patient pulse rate is high,was started on Beta blocker,(Tab.met Xl)tracheostomy was done on 11/1/23 and post tracheostomy spontaneous breathing trial was done and the patient was started on T piece ventilation but as the Bloodgas analysis showed metabolic acidosis with respiratory alkalosis,another episode of dialysis was done on 13/1/23 ,and in view of increasing counts,started on Inj.vancomycin according to renal clearance,and later as the oxygen wasn’t maintaining patient was shifted to CPAP and spontaneous breath trail was performed everyday, OMFS referral was taken for her tongue bite and the orders were followed,the GCS being E2V1M4,and the gag and brain stem reflexes were intact,and review mri scan was done on 13/1/23,to rule out any hypoxic injury to brain,and the MRI showed mild hypoxic ischemic encephalopathy changes in both cerebral hemishperes and basal ganglia,and for thromboprophylaxis DVT stockings were placed and advised for passive Physiotherapy,and patient is on conservative management,and she was managed with Intermittent CPAP With T piece support and the GCS today on 16-01-2023,being E2VtM4 ,patient attenders have been explained about the condition of the patient,and the prognosis of the patient in thier own understandable language,even explaining the risk of the patient condition after taking home,but the attenders dont want to stay and want to leave gainst medical advice. Investigation mri done on 3/1/23 impression :multiple areas of flair/t2 hyperintense signal in b/l subcortical white matter in both cerebral hemispheres -suggestive of posterior reversible encephalopathy syndrome

t2/flair hyperintensive signal seen in central pons with no obvious restricted diffusion- likely suggestive of osmotic demylenation syndrome mri done on 13/1/23: impression posterior reversible encephalopathy syndrome uremic encephalopathy osmotic demylenation syndrome thereis diffusion restriction in corpus callosum and rt parietal lobe likely hypoxic ischemic encephalopathy evidence of soft tissue swelling in occipital predominantly on left side 2d ECHO: 03-01-2023 Tachycardia No RWMA Mild LVH(1.18cms) Moderate TR with PAH(53mm of hg) Mild AR no MR Sclerotic Thickened AV EF = 58% Good LV systolic function Diastolic dysfunction No PE IVC size (1.09cms) collapsing. 12-01-2023 No RWMA Mild LVH(1.18cms) Trivial TR+/AR+ no MR Sclerotic Thickened AV No AS/MS EF = 58% Good LV systolic function Diastolic dysfunction No PE/PAH IVC size (1.10cms) collapsing. CULTURE AND SENSITIVITY 05-01-2023 Sputum for C/S : Normal Oropharyngeal Flora grown. Blood C/S : No Growthafter 24hrs of aerobic incubation Urine for C/S : No growth 06-01-2023

ET C/S : Normal oral flora grown. ET secretions for CBNAAT : No MTB Detected. 09-01-2023 CSF for C/S : No growth ET secretions : Oral flora seen Pus swab for C/S : Skin commensals grown. 12-01-2023 Blood C/S : Enterococci species isolated Urine C/S : Enterococci species isolated Treatment Given(Enter only Generic Name) 1. RT feeds 50 ml water with protein powder 2nd hrly , 100ml milk : 4th hrly, 2. Inj Meropenem 500mg/IV/BD 3. Inj Vancomycin 1gm /IV/OD4. Inj Pantop 40mg IV/OD 5. Inj Zofer 4m IV/OD6. Inj Neomol 100ml /IV /SOS7. Inj Vit K 1 amp in 100 ml NS/IV/OD 8. Inj Levipil 500mg in 100 ml NS/IV/BD 10. Inj EPO 4000 IU /SC/ twice weekly[given on 15-01-2023]11. Tab Voriconazole 100mg RT/BD12. Tab Isoniazid(245mg) + Tab Rifampicin (490mg) RT once daily 13.Tab Pyrazinamide(1225mg) + Tab Ethambutol(735mg) RT alternate day14.Tab Dolo 650mg /RT/ 6th hrly 15.Tab Atorvas 20mg /RT/H/s 16.Tab Amlong 10mg/RT/OD 17. Tab Nodosis 500mg /RT/BD 18. Syrup Potklor 15ml/RT/ TID 19. Nebulisation with Mucomist and Ipravent 6th hrly with chest physiotherapy20. DVT stocking 21. Airbed22. ABG monitored 6th hourly 23. Grbs monitored 4th hourly24. E/D Lubrex 0/0/0/0 both eyes 4times/ day25. E/D Moxiflox 0/0/0/0 both eyes 4times/ day26. Fudic cream L/A /BD/1week27. Zyte gel for L/A to lower lips 28. Neosporin powder L/A for bed sore29. Both upper limbs elevation30. Vitals monitored 2nd hrly 31.Tracheostomy suctioning done 2nd hrly with tracheostomy dressing done daily 32. Hemodialysis done on 05-01-2023, 08-01-2023 and 13-01-2023. Advice at Discharge Pateint's attenders have been clearly explained about the patient condition and the need for hospital stay for tracheostomy careand the need for bedsore management and cardiac monitoring in their own understandable language and the riskof death also has been explained but the patient's attenders are not willing for further hospital stay and management and want to leave against medical advice.

*Patient was followed up after discharge,and found out that she died at Home..

Case 5:

76 Female,

ALTERED SENSORIUM SECONDARY TO MENINGO ENCEPHALITIS (RESOLVED) 2.SECONDARY TO LEFT LOWER LIMB CELLULITIS WITH LEFT KNEE SEPTIC ARTHRITIS 3.RIGHT HEART FAILURE SECONDARY TO CHRONIC OBSTRUCTIVE PULMONARY DISORDER 4. ANEMINA ?NUTRITIONAL ANEMIA 5. TYPE II DIABTES MELLITUS 6. GRADE 1 BEDSORE Case History and Clinical Findings CHEIF COMPLAINTS: SWELLING OF LEFT LOWERLIMB SINCE 2MONTHS ALTERED SENOSRIUM SINCE 3DAYS SHORTNESS OF BREATH SINCE 3DAYS COUGH SINCE 2DAYS FEVER SINCE 2DAYS

HISTORY OF PRESENT ILLNESS:PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YEARS AGO AND THEN DEVELOPED MINOR ABRASION TO RIGHT LOWER LIMB AND THEN DEVELOPED RIGHT LOWER LIMB SWELLING TILL KNEE AND WAS DIAGNOSED TO BE HAVING RIGHT LOWER LIMB CELLULITIS AND FASCIOTOMY WAS DONE AND RESOLVED AFTER 2 MONTHS AND AT THE TIME DIABETES MELLITUS TYPE II WAS DIAGNOSED AND KEPT ON MEDICATION.SHE WAS NORMAL FROM THEN AND 20 DAYS BACK SHE DEVELOPED SUDDEN SWELLING OF LEFT LOWER LIMB TILL KNEE INTIALLY AND THEN PROGRESSED TO THIGH.SHE WENT TO LOCAL HOSPITAL AND FOUND TO HAVE LEFT LOWER LIMB CELLULITIS AND ON FURTHER EVALUATION FOUND TO BE HAVING EROSION OF KNEE JOINT AND WAS DIAGNOSED AS HAVING SEPTIC ARTHRITIS AND INCISION AND DRAINAGE WAS DONE AND LEFT KNEE OSTEOTOMY WAS DONE , FASCIOTOMY AND DEBRIDEMENT OF LEFT LOWER LIMB WAS DONE. 2 POINTS RED BLOOD CELLS TRANSFUSIONS WAS DONE AND DAILY DRESSING WAS DONE.SINCE 3 DAYS SHE DEVELOPED FEVER WHICH WAS INCIDIOUS IN ONSET,GRADUALLY PROGRESSIVE IN NATURE,HIGH GRADE,CONTINUOUS IN NATURE,WITH CHILLS AND RIGOR,RELIEVED ON MEDICATION.SHE DEVELOPED SHORTNESS OF BREATH SINCE 3 DAYS WHICH WAS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE IN NATURE FROM GRADE III TO IV , AGGREVATED ON WORK RELIEVED ON REST AND ALSO WAS ON ALTERED SENSORIUM SINCE 3 DAYS,WHICH WAS ACUTE INITIALLY,CONFUSED LATER AGITATED OVER 3DAYS PROGRESSIVE FROM CONFUSION TO AGITATION AND NOT REACTING TO SURROUNDING STIMULI.ON DAY OF ADMISSION WITH GCS BEING E1V2M4.NO URINE OUTPUT SINCE YESTERDAY NIGHT FOR WHICH FOLEYS CATHETER WAS PLACED TODAY MORNING AND SHE IS PASSING URINE NOW. PAST HISTORY: K/C/O DIABETES MELLITUS TYPE II ON TAB ZORYLMV1(METFORMIN 500 MG +GLIMEPERIDE 1MG+ VOGLIBOSE 0.2MG) SINCE 3 YEARS. NOT A K/C/O HYPERTENSION/ASTHMA/TUBERCULOSIS/EPILEPSY/CORONARY ARTERY DISEASE/CEREBRO VASCULAR ACCIDENT/THYROID DISORDERS. VITALS: TEMP: 97.7F. BP:120/70MMHG. PR:90BPM. RR:16CPM. SPO2:97. GRBS:211MG/DL. SYSTEMIC EXAMINATION: RESPIRATORY- B/L AIR ENTRY PRESENT; DIFFUSE WHEEZE PRESENT CARDIOVASCULAR- S1S2+ NO MURMUR PER ABDOMEN -SOFT NON TENDER CENTRAL NERVOUS SYSTEM- E2V2M4 NECKSTIFFNESS PRESENT KERNINGS SIGN POSITIVE TONE NORAML IN ALL FOUR LIMBS REFLEXES:- B T S A K P RT + + + + - F LT + + + + - F

COURSE IN THE HOSPITAL :- PATIENT PRESENTED TO THE CASULATY IN AN UNCONSCIOUS STATE (GCS- E1V2M4), SINCE 3DAYS WITH HIGHGRADE FEVER WITH CHILLS SINCE 3DAYS AND SHORTNESS OF BREATH SINCE 3DAYS. ON EVALUATION, BILATERAL PUPILS WERE REACTING TO LIGHT, NECKSTIFFNESS PRESENT,KERNINGS SIGN POSITIVE AT THE TIME OF ADMISSION.WITH FASCIOTOMY SCARS PRESENT OVER LEFT LOWER LIMB.WITH LEFT LOWERLIMB SWELLING TILL THIGH. FOLEYS CATHETERISATION WAS DONE IN SITU WE HAVE SUSPECTED HER TO HAVING ?MENINGOENCEPHALITIS SECONDARY TO LEFT LOWERLIMB CELLULITIS WITH LEFT KNEE ?SEPTIC ARTHRITIS. IV MEDICATIONS, I.V ANTIBIOTICS INJ.MONOCEF, SUBCUTANEOUS INSULIN AND NEBULISATION WERE STARTED. MRI BRAIN PLAIN WAS DONE WHICH SHOWED T2/FLAIR HYPERINTENSE SIGNALS SEEN IN LEFT SUPERIOR FRONTAL GYRUS INVOLVING WHITE MATTER WITH NO OBVIOUS RESTRICTED DIFFUSION- POSSIBBLE D/D'S FOCAL ENCEPHALITIS AND POST ICTAL EDEMA. MILD DIFFUSE CEREBRAL ATROPHY WTIH SMALL VESSEL DISEASE.. SURGERY OPINION WAS TAKEN AND DEBRIDEMENT FOR CELLULITIS UNDER LOCAL ANESTHESIA WAS DONE. ORTHOPEDICS OPINION WAS TAKEN FOR LEFT KNEE SEPTIC ARTHRITIS. ASPIRATION WAS DONE AND ASPIRATE IS 15ML AND IS SEROSANGUINOUS IN NATURE AND IS SENT FOR CULTURE AND SENSITIVITY AND SWAB TAKEN FROM LEFT LOWER LIMB WAS SENT FOR CULTURE AND SENSITIVITY AND BLOOD AND URINE WERE SENT FOR CULTURE AND SENSITIVITY. RYLES TUBE WAS PLACED. OPHTHALMOLOGY OPINION WAS TAKEN FOR RAISED INTRACRANIAL PRESSURE. NO SIGNS OF RAISED INTRACRANIAL PRESSURE FOUND DAY2:-PATIENT WAS DROWSY AND SAME TREATMENT WAS CONTINUED. AS THERE WERE NO SIGNS OF RAISED INTRA CRANIAL PRESSURE,LUMBAR PUNCTURE WAS DONE AND CULTURES WERE FOUND TO BE NEGATIVE. REGULAR DRESSINGS WERE DONE DAY3:- PATIENT WAS CONCIOUS BUT WAS NON COHERENT AND NOT ORIENTED TO TIME PLACE AND PERSON. PULMOLOGY OPINION WAS TAKEN I/V/O XRAY CHANGES OF PATIENT ?COR PULMONALE AND ADVICED TO CONTINUE SAME TREATMENT AND SYP. GRILLINCTUS WAS ADDED. INJ.FURESEMIDE WAS ADDED IF THE BP>110MMHG. REGULAR DRESSINGS WERE DONE DAY 4:-PATIENT WAS CONCIOUS,COHERENT NOT ORIENTED TO TIME PLACE PERSON.WEDGE BIOPSY WAS DONE. CONTINUED THE SAME TREATMENT AND REGULAR DRESSINGS WERE DONE

DAY5:-PATIENT WAS DROWSY BUT AROUSABLE NOT ORIENTED TO TIME,PLACE.ORIENTED TO PERSON,PSYCHIATRY OPINION WAS TAKEN AS THE ATTENDANTS WERE COMPLAINING OF INSOMNIA AND SLURRED SPEECH AND ADVICED TO CONTINUE SAME TREATMENT ANDT.OLANZAPINE 2.5MG IF THE PATIENT IS AGITATED. REGULAR DRESSING WERE DONE DAY6:-PATIENT IS DROWSY BUT AROUSABLE NOT ORIENTED TO TIME,PLACE AND PERSON. CONTINUED THE SAME TREATMENT AND SHE DEVELOPED GRADE 1 BED SORE AND SURGERY OPINION WAS TAKEN AND REGULAR DRESSINGS WERE DONE DAY7:-PATIENT IS ORIENTED TO PERSON PLACE AND NOTORIENTED TO TIME. SAME TREATMENT WAS CONTINUED AND REGULAR DRESSINGS WERE DONE DAY8-PATIENT IS ORIENTED TO TIME,PLACE AND PERSON. RYLES TUBE WAS REMOVED AS THE PATIENT IS ACCEPTING AND TOLERATING ORAL FLUIDS. SAME TREATMENT WAS GIVEN AND REGULAR DRESSINGS WERE DONE DAY9:-PATIENT IS ORIENTED TO PLACE NOT ORIENTED TO PERSON. SAME TREATMENT WAS GIVEN AND REGULAR DRESSINGS WERE DONE DAY10:-PATIENT IS DROWSY BUT AROUSABLE.SAME TREATMENT WAS GIVEN AND REGULAR DRESSINGS WERE DONE. FROM S/C INSULIN MEDICATIONS,SHE WAS CONVERTED TO METFORMIN ORALLY. Investigation HEMOGRAM HB (GM/DL) 9.0 - 9.4 -8.6 -9.5- 8.7-10.4-9.8 TLC (CELLS/CUMM) 29,800 -25,000-20,000-22,700-18,700-18,100-12,900 PLATELETS- (LAKHS/CUMM) 6.9-8.0-8.9-8.2-7.5-6.59-8.43 USG ABDOMEN IMPRESSION-MILD HEPATOMEGALY 2DECHO/11/01/23 NO RWMA MILD LVH(1.25CMS) MODERAE MR/TR WITH PAH : MILD AR SCLEROTIC THICKENED AV NO AS/MS EF= 60. GOOD LV SYSTOLIC FUCNTION IVC SIZE (1.45CMS) COLLAPSING MILD DILATED R.A/L.A 2DECHO REVIEW 16/01/2023 NO RWMA.MILD LCH(1.25CMS) MILD MR/TR WITH PAH ; MILD AR

SCLEROTIC,THICKENNED AV . NO AS EF= 60%GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION. NO PE IVC SIZE 1.21CMS CSF ANALYSIS PROTEIN 24 ; SUGAR 36 CELL COUNT 1 (LYMPHOCYTE PREDOMINANT) , NO ATYPICAL CELLS REPORTS DATE (12/01/23)- BLOOD, URINE AND CSF CULTURE NEGATIVE (13/01/23)-AURAL SWAB(CELLULITIS), LEFT KNEWW JOINT ASPIRATION- CURLTURES ARE NEGATIVE (16/01/23)-BLOOD CULTURES NEGATIVE (18/01//23)- BLOOD CULTURES NEGATIVE Treatment Given(Enter only Generic Name) 1. IV FLUIDS NS RL @100ML/HR. 2.INJ.MONOCEF 2GM IV STAT 3.INJ.MEROPENEM 500MG/IV/BD FOR 14DAYS 4.INJ.VANCOMYCIN 1GM/IV/BD IN 100ML NS OVER 45MIN FOR 7DAYS 6.INJ.HUMAN ACTRAPID INSULIN S/C /TID 14U-14U-14U 8AM -1PM-8PM 7.INJ.NPH/SC/BD 8AM-8PM 6U-6U. 8.INJ.FURSEMIDE 40 MG/IV/BD(IF SBP>110MMHG) 9.INJ DEXAMETHASONE 8MG/IV/TID 10.INJ.PANTOPRAZOLE 40MG/IV/OD 11.INJ.ONDANSETRON 4MG/IV/OD 12.TAB.METOPROLOL SUCCINATE 12.5 MG/PO/OD 13.TAB.OLANZAPINE 2.5MG PO/SOS 14.TAB.FERROUS ASCORBATE+FOLIC ACID PO/OD 15.TAB.METFORMIN500MG PO BD STARTED ON 19/1/23 15.SYRUP.AMBROXOL+LEVOSALBUTAMOL 1TSP/PO/TID. 16.NEB WITH ACETYLCYSTINE 6TH HOURLY AND BUDESONIDE 12TH HRLY 17.LEFT LOWER LIMB DRESSING AND ELEVATION 18.OINT.NEOMYCIN+POLYMYXIN-B FOR LOCAL APPLICATION OVER BEDSORE 19.PHYSIOTHERAPY OF LEFT LOWER LIMB(KNEE ROM) 20..BP TEMP MONITORING 2ND HRLY 21.MOBILISE THE PATIENT 22.PLENTY OF ORAL FLUIDS Advice at Discharge 1. TAB. METFORMIN 500MG ORALLY TWICE DAY AT 8AM AND 8PM

2. TAB. METOPROLOL SUCCINATE 12.5MG ORALLY ONCE A DAY AT 8AM 3. TAB. PANTOPRAZOLE 40MG/ORALLY/ONCE A DAY AT 7AM BEFORE FOOD 4. TAB.FERROUS SULPHATE + FOLLIC ACID ORALLY ONCE A DAY AT 2PM 5.TAB.ONDANSETRON 4MG ORALLY SOS 6.TAB.OLANZAPINE 2.5MG ORALLY SOS AT 8PM 7.SYP.ARISTOZYME 30ML ORALLY THRICE A DAY (20MINS BEFORE FOOD) 8AM--2PM--8PM 8.OINT. NEOMYCIN + POLYMYXIN- B, LOCAL APPLICATION FOR BED SORE 9. LEFT LOWERLIMB ELEVATION AND DRESSING OF THE PATIENT. 9.MOBILISE THE PATIENT 10. PLENTY OF ORAL FLUIDS

Outcome:

Patient was discharged in the current admission,with good recovery

Case 6:

57M,

ALTERED SENSORIUM (RESOLVED) SECONDARY TO ALCOHOL WITHDRAWL 2. K/C/O HYPERTENSION (SINCE 9 YEARS) 3. K/C/O TYPE II DIABETES MELLITUS( SINCE 9 YEARS) 4.H/O CEREBRO VASCULAR ACCIDENT 9 YEARS BACK WITH LEFT HEMIPARESIS SECONDARY TO CHRONIC INFARCT IN RIGHT PUTAMEN AND FRONTAL GYRUS . Case History and Clinical Findings PATIENT WAS BROUGHT TO THE CASUALTY INSTATE OF SUDDEN ONSET OF ALTERED SENSORIUM SINCE 5AM ON 24-01-23 HOPI : PATIENT WAS APPARENTLY ALRIGHT UNTILL 5AM ON 24-01-23 , HE WOKE UP THEN AND WENT TO OPEN THE DOOR AND HE LEANED ON TOTHE DOORAND DIDNOT OPEN THE DOOR. HE THEN PASSED URINE INVOLUNTARILY AND SINCE THEN HE IS NOT RECOGNISING HIS FAMILY MEMBERS .HE IS AGITATED WITH MOVING ALL UPPER AND LOWER LIMBS AND PT IS IN CONFUSED STATE WITH GCS E2V2M4 - E4V4M4-E4V5M6. NO NECK STIFFNESS

NO H/O LOSS OF CONSCIOUSNESS/VOMITINGS/DEVIATION OF MOUTH/NO UPROLLING OF EYEBALLS/NO TONIC OR CLONIC SEIZURES/ TRAUMA/FEVER PAST HISTORY : PATIENT IS A KNOWN CASE OF DIABETES MELLITUS TYPE 2 USING T METFORMIN 500 MG PO /OD ( ON REGULAR MEDICATION ) AND HYPERTENSION SINCE 9 YEARS (FOR HYPERTENSION PATIENT'S ATTENDANT DOESNT KNOW) PATIENT HAD CEREBRO VASCULAR ACCIDENT 9 YEARS BACK WITH LEFT HEMIPERESIS AND PATIENT RECOVERED NOW WITH MILD WEAKNESS OF LEFT UPPER AND LOWER LIMBS. NOT A K/C/O ASTHMA/EPILEPSY/TUBERCULOSIS/CAD/THYROID DISORDERS PERSONAL HISTORY: DIET MIXED SLEEP NORMAL APPETITE NORMAL BOWEL CONSTIPATION+ BLADDER NORMAL ADDICTIONS ALCOHOLIC SINCE 16YEARS ,LAST BINGE ON NIGHT BEFORE ADMISSION AND NON SMOKER NO SIGNIFICANT FAMILY HISTORY O/E PATIENT ON ADMISSION IS IN ALTERED SENSORIUM GCS E2V2M4 TEMP 99.4F PR 108BPM RR 22CPM BP 190/110 MM HG SPO2 97% AT ROOM AIR GRBS 365MG/DL CVS S1 S2 HEARD NO MURMURS RS BILATERAL AIR ENTRY+ NORMAL VESICULAR BREATH SOUNDS+ P/A SOFT NON TENDER BOWEL SOUNDS+ CNS : PATIENT IS IRRITABLE AND AGITATED INAPPROPRIATE SPEECH SIGNS OF MENINGEAL IRRITATION CANNOT BE ELICITED MOTOR SYSTEM INCREASED TONE IN BOTH UPPER AND LOWER LIMBS POWER COULDNT BE ELICITED BUT MOVING ALL LIMBS

REFLEXES BICEP TRI SUP KNE ANK PLA RT ++ ++ ++ ++ + F LT ++ ++ ++ ++ + F CEREBELLAR SIGNS : CANNOT BE ELICITED SENSORY EXAMINATION (BILATERALLY) SPINOTHALAMIC TRACT 1. CRUDE TOUCH - PRESENT 2.PAIN - PRESENT 3. TEMPERATURE - PRESENT POSTERIOR COLUMN 1.FINE TOUCH - PRESENT 2.VIBRATION (RIGHT AND LEFT) UPPERLIMB - 10SECONDS 10SECONDS UPPERLIMB SUPINATOR - 9SEC 9SEC LOWERLIMB TIBIA - 7SEC 8SEC LOWERLIMB MEDIAL MALLEOLUS - 6SEC 6SEC 3.JOINT POSITION - NOT ABLE TO TELL NOT ABLE TO TELL CORTICAL TRACT 1. GRAPHESTHESIA - PRESENT 2. STEROGNOSIS - PRESENT 3.TACTILE LOCALISATION - PRESENT O/E ON DISCHARGE PT IS ORIENTED TO TIME ,PLACE ,PERSON TEMP 99.4F PR 88BPM RR 18CPM BP 130/80 MM HG SPO2 97% AT ROOM AIR GRBS 152MG/DL CVS S1 S2 HEARD NO MURMURS RS BILATERAL AIR ENTRY+ NORMAL VESICULAR BREATH SOUNDS+ P/A SOFT NON TENDER BOWEL SOUNDS+ CNS : Page-3 MOTOR SYSTEM NORMAL TONE IN BOTH UPPER AND LOWER LIMBS

POWER R L UL 5/5 5/5 LL 5/5 5/5 REFLEXES BICEP TRI SUP KNE ANK PLA RT ++ ++ ++ ++ + F LT ++ ++ ++ ++ + F NO CEREBELLAR SIGNS FINGER TO FINGER TEST FINGER NOSE TEST RHOMBERG TEST STRAIGHT LEG WALKING TEST HEEL KNEE TEST COURSE IN THE HOSPITAL : ON DAY 1 A 65 YEAR OLD MALE WAS BROUGHT TO THE CASUALTY IN ALTERED SENSORIUM SINCE MORNING MRI BRAIN WAS DONE SHOWED HYPODENSE AREA SEEN IN RT SUPERIOR FRONTAL GYRUS AND RT PUTAMEN SUB ACUTE /OLD INFARCT , FEW HYPODENSE AREAS IN BILATERAL PERIVENTRICULAR WHITE MATTER SUGGESTIVE OF SMALL VESSEL ISCHEMIC DISEASE .AND RYLES TUBE WAS PLACED AND HE WAS MANAGED CONSERVATIVELY AND AS HE WAS HYPERTENSIVE SINCE 9 YRS AND DIABETIS MELLITUS TYPE 2 SINCE 9 YEARS AND INJ HUMAN ACTRAPID INSULIN WAS GIVEN @ 8AM 2 PM - 8 PM ACCORDING TO SLIDING SCALE AND ALL ROUTINE INVESTIGATIONS WERE SENT. DAY 2 PATIENT WAS IN ALTERED STATE BUT LESS AGITATED THAN YESTERDAY 2DECHO WAS DONE WHICH SHOWED CONCENTRIC LVH(1.48CMS) LV COLLAPSING NO RWMA MILD TR+ TRIVIAL AR+ NO MR SCLEROTIC AV NO AS/MS IAS INTACT EF 58% GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION NO PE IVC SIZE 1.09CMS

N VIEW OF ALCOHOL DEPENDENCE A PSYCHIATRY OPINION WAS TAKEN AND THEY ADVISED INJ LORAZEPAM SOS IF PATIENT IS MORE AGITATED. DAY 3 PATIENT WAS NORMAL TODAY ANDHE WAS WELL ORIENTED TO TIME PLACE AND PERSON AND NO COMPLAINTS. DAY 4 PATIENT'S ORIENTATION IMPROVED AND HE WAS SHIFTED TO WARD AND PSYCHIATRY REVIEW WAS DONE AND WAS ADVICED FOR TAB.LORAZEPAM SOS IF PATIENT IS AGITATED OR SLEEPLESS. PATIENT SLEPT WELL AND COMPLAINED OF SWAYING BUT CEREBELLAR SIGNS WERE NARMAL AND HE WAS TAKING ORALLY DAY 5 PATIENT GAVE NO COMPLAINTS AND WITH STABLE VITALS HE WAS DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION. Investigation MRI BRAIN : 1.NO ACUTE INTRACRANIAL BLEEDS 2.HYPODENSE AREA SEEN INN RIGHT SUPERIOR FRONTAL GYRUS AND RIGHT PUTAMEN SUBACUTE/OLD INFARCT 3.FEW HYPODENSE AREAS IN BILATERAL PERIVENTRICULAR WHITE MATTER SUGGESTIVE OF SMALL VESSEL ISCHEMIC DISEASE 2D ECHO : CONCENTRIC LVH(1.48CMS) LV COLLAPSING NO RWMA MILD TR+ TRIVIAL AR+ NO MR SCLEROTIC AV NO AS/MS IAS INTACT EF 58% GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION NO PE IVC SIZE 1.09CMS USG ABDOMEN: NO SONOLOGICAL ABNORMALITY DETECTED ECG : NORMAL SINUS RHYTHM Treatment Given(Enter only Generic Name) 1. IV FLUIDS NS@50ML/HR 2. RT FEEDS 100ML MILK 4TH HRLY AND 50ML WATER 2ND HRLY 3. TAB ECOSPIRIN AV (75/10) RT/OD(9PM) 4. INJ HUMAN ACTRAPID INSULIN S/C ACCORDING TO SLIDING SCALE

5. INJ THIAMINE 200MG/IV/TID6. INJ LORAZEPAM 2 MG HALF AMPULE/IM/SOS 7. TAB TELMA 40MG/RT/OD AT 8AM 8. GRBS 6TH HRLY 9. BP MONITORING HRLY 10. I/O CHARTING Advice at Discharge 1. PLENTY OF ORAL FLUIDS 2. TAB GLIMI M1 ONCE DAILY PER ORAL BEFORE BF 3. TAB THIAMINE 200MG PER ORAL TWICE DAILY AT 8AM AND 8PM FOR 15 DAYS 4. TAB ECOSPRIN AV75/10MG PER ORAL BED TIME 5. TAB TELMA 40MG PER ORAL ONCE DAILY AT 8AM 6. TAB PREGABALIN M 75MG/PER ORAL BED TIME AT 9PM 7. SYRUP CREMAFFIN PLUS 10ML/PER ORAL BED TIME AT 9PM 8. PHYSIOTHERAPY DAILY .

*Outcome:. patient is good at the time of discharge,,

GOOD RECOVERY

Case 7:

71,M

Diagnosis Death Date: 27/01/2023 09:15 AM 1) PAROXYSMAL ATRIAL FIBRILLATION ( SECONDARY TO HEART FAILURE) 2) CHRONIC DECOMPENSATED LIVER DISEASE WITH HEPATIC GRADE 1 ENCEPHALOPATHY , LEFT PLEURAL EFFUSION AND ASCITES 3) HEART FAILURE WITH PRESERVED EJECTION FRACTION ( EF60%) 4) PRENAL ACUTE KIDNEY INJURY 5)H/O CEREBROVASCULAR ACCIDENT WITH LEFT HEMIPARESIS ( 1 YEAR BACK) Case History and Clinical Findings CHIEF COMPLAINTS C/O GENERALISED BODY SWELLING SINCE 1 WEEK C/O SHORTNESS OF BREATH SINCE 2DAYS C/O DECREASED URINE OUTPUT SINCE MORNING HISTORY OF PRESENT ILLNESS :PATIENT WAS APPARENTLY ALRIGHT 1 YEAR BACK THEN HE HAD LEFT HEMIPARESIS FOR WHICH HE USED HERBAL MEDICATION AND THEN RESOLVED AFTER 3DAYS (POWER IMPROVED ). 6 MONTHS BACK HE HAD PEDAL OEDEMA WHICH IS PITTING TYPE TILL KNEE AGGREVATED ON SLEEPING (INTERMITTENT ) WHICH RELIEVED ON WALKING C/O COUGH SINCE 1 MONTH, PRODUCTIVE IN NATURE,SCANTY SPUTUM NON BLOODSTAINED, INTERMITTENT COUGH WHICH RELIEVED AFTER TAKING MEDICATION. C/O PEDAL EDEMA SINCE 1 WEEK, FROM LOWER LIMBS AND GRADUALLY PROGRESSED TO ENTIRE BODY C/O SHORTNESS OF BREATH SINCE 2DAYS. NYHA GRADE II PROGRESSED TO GRADE III FROM 1 WEEK . SOB EVEN AT REST ORTHOPNEA PRESENT PND,LOSS OF APPETITE,WEIGHT LOSS ,CHEST PAIN ,PALPITATIONS WERE ABSENT . PAST HISOTRY NOT A KNOWN CASE OF HYPERTENSION, DIABETES MELLITUS,TUBERCULOSIS, BRONCHIAL ASTHMA, EPILEPSY,CORONARY HEART DISEASE. H/O OLD CVA WITH LEFT HEMIPARESIS 1 YR BACK . VITALS AT PRESENTATION BP-140/70MMHG PR-150BPM RR-20CPM GRBS-176MG/DL SPO2-98 % ON RA CNS - PATIENT WAS DROWSY BUT AROUSABLE ; E3 V4M5 MENINGEAL SIGNS WERE ABSENT TONE- NORMAL IN BILATERAL UPPER AND LOWER LIMBS POWER R L U/L 5/5 5/5 L/L 5/5 5/5 REFLEXES B T S K A P R + + + + + flexion L + + + + + flexion

CVS- S1S2 HEARD; NO MURMURS RESPIRATORY- BILATERAL AIR ENTRY PRESENT ; NO ADDED SOUNDS PERABDMEN- SOFT ; DISTENDED; NO TENDERNESS PRESENT BOWEL SOUNDS HEARD COURSE IN THE HOSPITAL A 70 YEAR OLD MALE CAME TO THE CASUALTY WITH COMPLAINTS OF GENERALISED BODY SWELLING SINCE 1 WEEK, SHORTNESS OR BREATH SINCE 2DAYS AND DECREASED URINE OUTPUT SINCE MORNING, WAS DROWSY AT THE TIME OF ADMISSION AND INITIAL EVALUATION WAS DONE TO RULE OUT THE CAUSE OF FLUID OVERLOAD AND ON FURTHER INVESTIGATIONS WAS FOUND TO BE HAVING DECOMPENSATED CHRONIC LIVER DISEASE WITH HEPATIC ENCEPHALOPATHY WITH A CHEST X-RAY SHOWING LEFT SIDED PLEURAL EFFUSION WITH USG ABDOMEN SHOWING MODERATE ASCITES. AS THE PATIENT IS DROWSY AND DIDN’T PASS STOOLS, ENEMA WAS PLACED AND THE PATIENT PASSED STOOLS AND USG CHEST WAS DONE AND SHOWED MODERATE EFFUSION WITH INTERNAL ECHOES NOTED IN LEFT PLEURAL SPACE WITH COLLAPSE OF UNDERLYING LUNG SEGMENT AND MILD PLEURAL EFFUSION WITH THICK SEPTATIONS NOTED IN RIGHT PLEURAL SPACE AND AS THE PATIENT IS DROWSY, RYLE’S TUBE WAS PLACED AND FEEDS WAS GIVEN AND IN VIEW OF CHRONIC DECOMPENSATED LIVER DISEASE, INJ. VITAMIN K WAS GIVEN AS A PROPHYLACTIC MEASURE TO PREVENT BLEEDING AND AS HE IS HAVING HEART FAILURE WITH PRESERVED EJECTION FRACTION (EF60%)PRELOAD REDUCING AGENTS WERE GIVEN BY MONITORING SERUM ELECTROLYTES VALUES AND OSMOTIC LAXATIVES WERE ADDED TO PASS STOOLS (3TIMES PER DAY) ON DAY 3 OF ADMISSION HE SUDDENLY DEVELOPED IRREGULAR HEART RATE AND THE ECG WAS SHOWING IRREGULARLY IRREGULAR HEART RATE AND ABSENT P WAVES AND RATE CONTROLLING AGENTS AND RHYTHM CONTROLLING DRUGS WERE STARTED WITH INJ. AMIODARONE INFUSION STARTED AT 150 MG/IV STAT FOLLOWED BY 600 MG IN 50 ML NS FOR 6 HRS @ 5 ML /HR . AS THE PERIPHERAL ACCESS COULDN’T BE FOUND, THEN CENTRAL CANNULA WAS PLACED IN THE RIGHT FEMORAL VEIN. PROCEDURE WAS UNEVENTFUL.ABG AND ECG MONITORING WERE DONE 6TH HOURLY AS THE PATIENT IS TACHYPNIC AS THE SATURATION OF OXYGEN WAS NOT MAINTAINING ON ROOM AIR. ABG MONITORED 6THOURLY AND ECG WAS DONE TO LOOK FOR THE HEART RATE RHYTHM

8:00AM IN THE MORNING (27/01/23) PATIENT HAD SUDDEN BLEEDING FROM NASAL AND ORAL CAVITY . HE WAS IN A DROWSY STATE AND SUDDENLY DEVELOPED BRADYCARDIA AND THE CENTRAL AND PERIPHERAL PULSES COULDN’T BE FELT AND THE PATIENT WAS INTUBATED WITH ET TUBE NO.7 M, AFTER DIRECT VISUALISING THE VOCAL CORDS WITH LARYNGOSCOPE, RAPID SEQUENCE INTUBATION WAS DONE AND THE CARDIOPULMONARY RESUSCITATION WAS INITIATED ACCORDING TO THE AMERICAN HEART ASSOCIATION 2020 GUIDELINES AND CPR WAS CONTINUED FOR 30MINS. DESPITE OF ALL RESUSCITATIVE EFFORTS PATIENT COULDN’T BE RECOVERED AND DECLARED DEAD AT 9:12 AM ON 27/1/23 IMMEDIATE CAUSE OF DEATH- PAROXYSMAL ATRIAL FIBRILLATION (SECONDARY TO HEART FAILURE)- CHRONIC DECOMPENSATED LIVER DISEASE WITH HEPATIC ENCEPHALOPATHY, LEFT PLEURAL EFFUSION AND ASCITES- HEART FAILURE WITH PRESERVED EJECTION FRACTION (EF 60%)- PRE RENAL ACUTE KIDNEY INJURY ANTECEDENT CAUSE OF DEATH-H/O CEREBRAL VASCULAR ACCIDENT WITH LEFT HEMIPARESIS (1 YEAR BACK) Investigation HB-13.9GM/DL TLC-11,650 CELLS/CUMM PLT-1.50LAKHS/CUMM 26/01/23 USG CHEST :- E/O MODERATE RFFUSION WITH INTERNAL ECHIES NOTED IN THE LEFT PLEURAL SPACE, WITH COLLAPSE OF UNDERLYING LUNG SEGMENT E/O MILD PLEURAL EFFUSION WITH THICK SEPTATIONS NOTED IN THE RIGHT PLEURAL SPACE USG ABDOMEN 26/01/23 RAISED ECHOGENICITY OF BOTH KIDNEYS MODERATE ASCITES GRADE I FATTY LIVER 2DECHO 25/01/23 NO RWMA. MILD LVH(1.23CMS)

MODERATE TR AND PAH (52 + 10 62MMHG) MILD AR/MR SCLEROTIC AV, NO AS/MS EF=60 GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION MILD PLEURAL EFFUSION IVC SIZE (1.83CMS) DILATED NON COLLAPSING DILATED R.A/R.V/L.A/IVC Treatment Given(Enter only Generic Name) INJ. LASIX 40 MG IV BD TAB RIFAGUT 550MG PO BD TAB UDILIV 300MG PO BD TAB ECOSPIRIN AV 75/10 PO BD SYP LACTULOSE 30ML PO HS INJ. VITAMIN K IV OD INJ. ADRENALINE 1MG

Patient outcome:.

Patient Died in the hospital

Case 8:

58M,

Diagnosis Death Date: 25/01/2023 10:05 PM UROSEPSIS WITH MODS (AKI, ALI, HYPOTENSION); SEPTIC SHOCK AND DIC ICD 10 CODE R65.21 Case History and Clinical Findings CHEIF COMPLAINTS: PATIENT CAME WITH C/O NOT PASSING URINE SINCE YESTERDAY EVENING C/O FEVER - 1SPIKE YESTERDAY MORNING HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 20 DAYS BACK THEN HE DEVELOPED FEVER, ON AND OFF TYPE, WITH URINARY INCONTINENCE SYMPTOMS. FEVER IS HIGH GRADE, WITH JAUNDICE FOR WHICH HE TOOK TREE MEDICATION; AND FEVER WAS INTERMITTENT IN NATURE, WITH CHILLS AND RIGORS, RELIEVED ON TAKING ON MEDICATION. ANURIA SINCE LAST NIGHT PATIENT WAS BROUGHT IN GASPING STATE TO CASUALTY BY HIS ATTENDERS, AND ON PRESENTATION BP WAS UNRECORDABLE. PAST HISTORY: NOT A KNOWN CASE OF DM, HTN, CAD,CVA, EPILEPSY,TB

PERSONAL HISTORY APPETITE : NORMAL DIET: MIXED BOWEL AND BLADDER MOVEMENTS : REGULAR OCCASSIONAL DRINKER FAMILY HISTORY NOT SIGNIFICANT GENERAL PHYSICAL EXAMINATION NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA VITALS TEMP : AFEBRILE PR 147BPM RR 16CPM BP : 80/60MMHG SPO2 98% AT RA SYSTEMIC EXAMINATION CVS S1 AND S2 HEARD NO MURMURS HEARD RESPIRATORY SYSTEM BAE+; NVBS + P/A : SOFT, NON TENDER; BOWEL SOUNDS POSITIVE CNS : PATIENT IS IN STUPOR NO MENINGEAL SIGNS, NO CEREBELLAR SIGNS.

DEATH SUMMARY : A 60 YR OLD MALE WAS BROUGHT TO CASUALTY ON 25/01/23 AT 11:30 AM IN THE GASPING STATE WITH GCS:E2V1M1 WITH COMPLAINING OF ANURIA SINCE YESTERDAY EVENING 6:00 PM AND 1 FEVER SPIKE IN THE MORNING HIGH WAS RELIEVED ON MEDICATION. AT PRESENTATION SATURATION WAS 46% ON RA AND BP WAS NON RECORDABLE AND PR WAS 68BPM. PERIPHERAL PULSES WERE NOT PALPABLE AND CENTRAL PULSES ARE FEEBLE. ABG SHOW HIGH ANION GAP(METABOLIC ACIDOSIS). PATIENT WAS INTUBATED IN VIEW OF BRADYCARDIA AND FALL IN SATURATION WITH ET 7.0 CMS, CONNECTED TO MECHANICAL VENTILATOR. FLUID RESUSCITATION WAS DONE AND NORADRENALINE WAS STARTED FOR HYPOTENSION AND AFTER 1 HOUR INJ VASOPRESSIN AND INJ DOBUTAMINE WERE ALSO STARTED AS BP WAS STILL NOT RECORDABLE. PATIENT WAS TREATED WITH IV ANTIBIOTICS, IV FLUIDS AND SUPPORTIVE CARE. TRIPLE LUMEN WAS PLACED IN RIGHT FEMORAL VEIN AND INOTROPE SUPPORT CONTINUED. INSPITE OF ALL ABOVE MEASURES BP WAS NOT RECORDABLE AND AT 9:35 PM PATIENT HAD SUDDEN BRADYCARDIA AND CENTRAL PULSE WAS NOT FELT AND CPR WAS DONE FOR HALF AN HOUR; INSPITE OF ALL THE EFFORTS PATIENT COULDNT BE REVIVED AND WAS DECLARED DIED AT 10:05PM WITH ECG SHOWING FLAT LINE AND NO ELECTRICAL ACTIVITY IMMEDIATE CAUSE : UROSEPSIS WITH MODS(AKI, ALI, HYPOTENSION) SEPTIC SHOCK AND DIC ICD 10 CODE - R65.21 ANTECEDENT CAUSE : UROSEPSIS Investigation HEMOGRAM : TC 74000 HB 11.3 MCV 104.5 MCH 33.5 MCHC 32.1 PLT 1.73 LAKH RBS 88 LFT : TB 16.14; DB 8.69;SGOT 396; SGPT 150; ALP 673; TP 5.7; ALB 2.0; A/G 0.57

RFT : UREA 107; CREATININE 3.7; URIC ACID 8.0; CALCIUM 10.2; PHOSPHORUS 5.3; SODIUM 144; POTASSIUM 2.4; CHLORIDE 103 SEROLOGY- HBSAG AND HIV 1 AND 2 - NEGATIVE SERUM LACTATE - 11.7 MG/DL MAGNESIUM 2.0 C REACTIVE PROTEIN : POSITIVE(1.2MG/DL) D DIMER 130NG/ML CUE : COLOUR : PALE YELLOW APPEARANCE : CLOUDY REACTION : ACIDIC SP GRAVITY: 1.010 ALBUMIN : ++++ SUGAR: NIL BILE SALTS AND PIGMENTS : NIL PUS CELLS 6-8 EPITHELIAL CELLS 1-2 CAST- BILIRUBIN AND GRANULAR CASTS PRESENT BLOOD GROUPING AND TYPING : O +VE ABG PH 7.117 PCO2 32.1 PO2 56.2 OXIMETRY VALUES ctHb 11.6 g/dl

sO2 76.3 cHCO3 (P st) 10.7 c HCO3(P) 9.9 ANION GAP 16.3 mmol/l ANION GAP K+ 20.2 mmol/l Treatment Given(Enter only Generic Name) 1) RT FEEDS - MILK 200ML 4TH HRLY; WATER -200ML - 2ND HRLY 2) INJ NORAD 2 AMP IN 46ML NS 3) INJ VASOPRESSIN 2 AMP IN 46 ML NS 4) IV FLUIDS DNS AND NS @30ML/HR 5) INJ ATRACURIUM 2CC IV/STAT 6) INJ DOBU 1AMP IN 46ML NS 7) INJ MEROPENEM 1GM/IV/STAT FOLLOWED BY INJ MEROPENEM 500MG IV/BD 8) FENTANYL 200MG(4ML) + 2AMP MIDAZ 30G(30ML) + 34ML NS @4ML/HR 9) TAB UDILIV 300MG RT/BD 10) SYP LACTULOSE 15ML RT/BD 11) TAB DOLO 650MG RT/TID 12) INJ NEOMOL 1GM IV/SOS 13) INJ THIAMINE 200MG IV/BD 14) INJ OPTINEURON 1AMP 100ML NS IV/OD

Patient Died in the hospital

Case 9:

86F,

Diagnosis HEART FAILURE WITH REDUCED EJECTION FRACTION SECONDARY TO CORONARY ARTERY DISEASE(EF 30%) WITH ANTERIOR WALL MI WITH TRUE HYPONATREMIA SECONDARY TO SIADH(RESOLVED) AND HYPOKALEMIA (RESOLVED) WITH BILATERAL LUNG CONSOLIDATION Case History and Clinical Findings COMPLAINTS OF IRRELAVANT TALK AND AKTERED MENTAL STATUS SINCE 10 DAYS COMPLAINTS OF SHORTNESS OF BREATH SINCE 3 DAYS COMPLIANTS OF COUGH SINCE 3 DAYS HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS AGO AND THEN SHE DEVELOPED ALTERED MENTAL STATUS ON AND OFF AND HER SPEECH WAS INCOHERENT AT TIMES AND BECOMING NORMAL ON HER OWN. EACH EPISODE LASTED 10 MINS

COUGH WAS PRODUCTIVE TYPE 2 DAYS AGO WITH WHITE SPUTUM'MUCOID CONSISTENCY AND SCANTY IN AMOUNT , NOW IT IS OF DRY TYPE SHE ALSO HAD SHORTNESS OF BREATH WHICH WAS GRADE III INITILLY AND THEN PROGRESED TO GRADE IV FOR WHICH SHE WENT TO LOCAL HOSPITAL AND ECHO WAS DONE- CAD (LAD TERRITORY) GLOBAL HYPOKINESIA, SEVERE LV DYSFUNCTION NO H/O OTHOPNEA, PAROXYSMAL NOCTURNAL DYSPNOEA , PALPITATIONS, CHEST PAIN, GIDDINESS PAST ILLNESS: NOT A KNOWN CASE OF HTN, DM, CVA, ASTHMA,EPILEPSY, TB PERSONAL HISTORY: DIET- MIXED APPETITE- DECREASED BOWEL AND BLADDER MOVEMENTS- REGULAR SLEEP- ADEQUATE ADDICTIONS- NONE ON EXAMINATION AT ADMISSION: PATEINT IS CONSCIOUS, COHERENT, COOPERATIVE NO PALLOR ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA BP- 90/50MMHG PR- 85BPM RR-24CPM SPO2- 88%@RA 95% ON 8L OF O2 GRBS- 126MG/DL CVS-S1 S2 + RS- BAE+, B/L BASAL CREPTS HEARD PA- SOFT NON TENDER CNS- NFD ON EXAMINATION AT DISCHARGE: PATEINT IS CONSCIOUS, COHERENT, COOPERATIVE BP- 90/50MMHG

PR- 72BPM SPO2- 98%@RA GRBS- 82MG/DL CVS-S1 S2 + RS- BAE+, B/L BASAL CREPTS HEARD, RT IAA CREPTS +, BRONCHIAL BREATH SOUNDS + PA- SOFT NON TENDER CNS- NFD BRIEF COURSE IN HOSPITAL-ON DAY 1 PATIENT PRESENTED WITH ABOVE COMPLAINTS WAS INITIALLY CONSCIOUS, COHERENT AND COOPERATIVE .AT THE TIME OF ADMISSION HER BP WAS 90/50 WITH OUTSIDE ECHO SHOWING CAD(LAD TERRITORY) WITH GLOBAL HYPOKINESIA AND SEVERE LV DYSFUNCTION.THEN DIURETICS AND ANTIPLATELETS WERE STARTED.MONITORING HER BP AND CARDIOLOGY CONSULTATION WERE TAKEN ON 3/2/23 I/V/O CORONARY ARTERY DISEASE AND CARDIOLOGIST ADVICED INJ.HEPARIN 4000 IU/IV/BD AND TAB.CAVERDILOL 3.125 MG WAS ADVICED AND ADVICE FOLLOWED AND HER SODIUM AND POTASSIUM LEVELS FOUND TO BE LOW AND ORAL POTASSIUM SUPPLIMENTATION WAS GIVEN AND HER TRUE HYPONATREMIA WAS ATTRIBUTED TO ?SIADH. AS HER CHEST X RAY SHOWED MIDDLE LOBE CAVITY OF RT.LUNG USG CHEST WAS DONE WHICH SHOWED BILATERAL PLEURAL EFFUSION(TAP NOT DONE).ON 3/2/23 OPTHALMOLOGY REFERRAL WAS DONE I/V/O RAISED ICT FEATURES AND ADVICE FOLLOWED ON 4/2/23 PULMONOLOGY REFERRAL WAS DONE I/V/O X RAY CHANGES AND ADVICE FOLLOWED.ON 3/2/23 PT MEAN ARTERIAL PRESSURE WAS NOT MAINTAINED AND WAS STARTED ON INJ.NORAD AND ADJUSTED ACCORDING TO HER BP .X RAY REPORTING WAS DONE AND SHOWED BILATERAL LUNG CONSOLIDATION WITH MILD CARDIOMEGALY.PATIENT WAS IRRITABLE DUE TO ?ICU PSYCHOSIS AND ANXIOLYTICS WERE GIVEN.NEXT DAY AS HER MEAN ARTERIAL PRESSURE WAS NOT MAINTAINED INJ.DOBUTAMINE 250 MCG IN 50ML NS WAS STARTED AND TAPERED AS HER BP IMPROVEDPATIENT WAS ADEQUATELY TREATED.PATIENT CONDITION IMPROVED AND DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION Investigation USG ABDOMEN-NAD USG CHESTRIGHT MILD PLEURAL EFFUSION HEMOGRAM ON 3/2/23 HB- 10.7 GM/DL

TLC- 10,300 CELLS/CUMM PLATELETS- 3.77 LAKHS/CUMM N/L/E/M/B- 74/16/01/09/00 PCV- 32.3 VOL% MCV- 85.7 FL MCH- 28.4 PG MCHC- 33.1% RBC- 3.77 IMPRESSION- NORMOCYTIC NORMOCHROMIC BLOOD PICTURE HEMOGRAM ON 8/2/23 HB- 9.9 GM/DL TLC- 5700 CELLS/CUMM PLATELETS- 3.27 LAKHS/CUMM N/L/E/M/B- 57/26/02/15/00 PCV- 31.4 VOL% MCV- 88 FL MCH- 27.7 PG MCHC- 31.5% RBC- 3.57 IMPRESSION- NORMOCYTIC NORMOCHROMIC ANEMIA WITH MONOCYTOSIS 2DECHOESD- 5.44CMS EDD- 6.3CM DPW- 1CM EF- 30% FS- 15% SEVERETR WITH PAH, MILD MR/AR GLOBAL HYPOKINETIC NO AS/MS SCLEROTIC AV MODERATE LV DYSFUNCTION NO DIASTOLIC DYSFUNCTION

REVIEW 2D ECHO ON 6/2/23 GLOBAL HYPOKINETIC MODERATE TR WITH PAH, MILD MR, MODERATE AR NO AS/MS, SCLEROTIC AV EF=30 MODERATE LV DYSFUNCTION NO DIASTOLIC DYSFUNCTION IVC SIZE COLLAPSING MILD DILATED LA/LV DILATED RA.RV NO PAH/PE Treatment Given(Enter only Generic Name) T. ECOSPRIN GOLD PO HS [75/75/10 MG] T. MET XL 25MG PO OD INJ LASIX 20MG IV BD INJ NORAD DS 2AMP IN 46ML NS IV @ 6ML/HR FLUID RESTRICTION O2 SUPLEMENTATION TO MAINTAIN SPO2>94% Advice at Discharge T. ECOSPRIN GOLD 75/75/10 MG PO/HS T.DYTOR 5MG PO/OD 9AM--*--* T.CARDIVAS 3.125MG PO/OD 8AM--*--* FLUID RESTRICTION <1LTR/DAY

*Discharged in the present admission,and died after 2 months in followup.*

Case 10:

71M,

ALTERED SENSORIUM SECONDARY TO HYPOGLYCEMIA (RESOLVED), ? OHA INDUCED HYPOGLYCEMIA, HFmEF (EF :50%), RIGHT GREAT TOE GANGRENE WITH AKI ON CKD ANEMIA UNDER EVALUATION ?IDA HYPERKALEMIA (RESOLVED) DM SINCE : 20 YEARS Case History and Clinical Findings PATIENT WAS BROUGHT TO THE CASUALITY IN AN UNCONSCIOUS STATE .PATIENT WAS APPARENTLY NORMAL UNTIL 9PM YESTERDAY NIGHT , THEN HE SUDDENLY WENT INTO THE STATE OF UNCONSCIOUSNESS AFTER EATING FOOD , NOT ASSOCIATED WITH VOMITING , SEIZURES,CHEST PIAN , PALPITATIONS , INVOLUNTARY MICTURITION , FROATHING FROM MOUTH .NO H/O FALL , TRAUMA TO HEAD,GIDDINESS ,FEVER , BURNING MICTURITION. PAST HISTORY:K/C/O DM SINCE 20YEARS AND ON T.GLIMI M1 NO H/O HTN/EPILEPSY/TB/CVD/CAD

H/O TRAUMA TO RIGHT LOWER LIMB FOR WHICH TIMELY INTERVENTION WAS DONE AT A LOCAL HOSPITAL , BUT STILL GANGRENOUS GREAT TOE + PERSONAL HISTORY : APPETITE - NORMAL DIET - MIXED BOWEL AND BLADDER - REGULAR SLEEP - ADEQUATE GENERAL EXAMINATION : PT IS C/C/C NO PALLOR, ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY,PEDAL EDEMA VITALS ON ADMISSION: TEMP- 98.5 PR-90 BPM BP- 160/90MM HG RR-16 CPM SPO2- 100% AT RA GRBS - 33 MG/DL SYSTEMIC EXAMINATION: 1) PER ABDOMEN: INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS. PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY. ASCULTATION: BOWEL SOUNDS - HEARD 2)RESPIRATORY SYSTEM: INSPECTION:SHAPE OF THE CHEST IS ELLIPTICAL,B/L SYMMETRICAL.BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS. PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS ,TRACHEA IS CENTRAL IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL .VOCAL FREMITUS IS NORMAL PERCUSSION: RESONANT B/L ASCULTATION: BAE + , NVBS HEARD, LEFT IMA CREPTS + 3) CVS: INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS. PALPATION: APEX BEAT FELT IN LEFT 5TH ICS.NO THRILLS AND PARASTERNAL HEAVES.

ASCULTATION: S1S2 +,NO MURMURS 4) CNS: PATIENT WAS C/C/C. HIGHER MENTAL FUNCTIONS- INTACT GCS - E4V5M6 B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEMNORMAL, MOTOR SYSTEM: TONE- NORMAL, POWER- 5/5 IN ALL LIMBS REFLEXES : BICEPS - 1+ , TRICEPS-1+ , SUPINATOR - ,KNEE - 1+ , ANKLE - 1+ REFERRALS TAKEN: 1. OPTHALMOLOGY :I/V/O RAISED ICT - FUNDUS EXAMINATION REVEALED CATARACTOUS LENS- ADVISED B/L CATARACT SURGERY 2. SURGERY:I/V/O RIGHT GREAT TOE GANGRENE- SUGGESTED RAY AMPUTATION UNDER SA OR ANKLE BLOCK. BRIEF COURSE IN HOSPITAL: PATIENT WAS BROUGHT TO CASUALITY WITH ABOVE MENTIONED COMPLAINTS AND NECESSARRY INVESTIGATIONS WERE SENT AND AS PATIENT WAS UNCONSCIOUS UPON EVALUATION HIS GRBS WAS 33 MG/DL FOR WHICH 25D WAS GIVEN , POST WHICH HE REGAINED CONSCIOUSNESS. INSPITE OF 25 D INFUSION PATIENT HAD REPEATED EPISODES OF HYPOGLYCEMIA FOR WHICH HE WAS TREATED SYMPTOMATICALLY. AFTER PATIENT WAS STABILISED SURGERY RFERRAL WAS TAKENI/V/O RIGHT GREAT TOE GANGRENE- SUGGESTED RAY AMPUTATION UNDER SA OR ANKLE BLOCK . SO DOPPLER OF RIGHT LOWER LIMB WAS DONE ,WHICH SHOWED: NO FLOW SEEN IN DISTAL PTA.POPLITEAL,PROXIMAL PTA, ATA DPA SHOWS BIPHASIC WAVEFORM LIKELY PVD,NO DVT ,MODERATE ATHEROSCLERTIC CHANGES NOTED IN EXAMINED ARTERIES.FOLLOWING THIS, NOW THE PATIENT IS BEING REFERRED TO KHL FOR REVASCULARIZATION SURGERY OF RIGHT LOWER LIMB . Investigation 1.HEMOGRAM: 4/02/23 HB:7.3 MG/DL TLC: 12000 CELLS/CUMM PLAT: 2.9 LAKH/CUMM

7/02/23 HB : 6.3 mg/dl PCV : 34.4% TLC : 6900 CELLS/CUMM PLT : 3.2 LAKH/CUMM 2. USG ABDOMEN: RIGHT GRADE 3 RPD CHANGES LEFT GRADE 2 RPD CHANGES B/L SIMPLE RENAL CORTICAL CYST GRADE 1 PROSTOMEGALY 3. DOPPLER OF RIGHT LOWER LIMB: NO FLOW SEEN IN DISTAL PTA. POPLITEAL,PROXIMAL PTA, ATA DPA SHOWS BIPHASIC WAVEFORM LIKELY PVD NO DVT MODERATE ATHEROSCLERTIC CHANGES NOTED IN EXAMINED ARTERIES. 4)2D ECHO : NO RWMA , MILD LVH+ MODERATE TR+ WITH PAH MILD AR+/ MR+, MILD GLOBAL HYPOKINESIA ,NO AS/MS SCLEROTIC AV, EF=50% FAIR LV SYSTOLIC FUNCTION, DIASTOLIC DYSFUNCTION +, NO PE. 5) URINE C/S: NO GROWTH DETECTED Treatment Given(Enter only Generic Name) 1.IVF 1NS @ 75 ML/HR 2.INJ CEFTRIAXONE 1 GM IV BD - D3 ON 7/2/23 3.INJ LASIX 40 MG IV BD 4.T ECOSPIRIN GOLD 75/75/20 PO HS 5.T RAMIPRIL 2.5 MG PO OD 6.T CARVIDIOL 3.125 MG PO OD 7.T OROFER XT PO OD 8.PLENTY OF ORAL FLUIDS 9.INJ HAI S/C ACC TO GRBS

Advice at Discharge 1.T TAXIM 200 MG PO BD 2.T LASIX 40 MG PO BD 8AM ------4PM 3.T ECOSPIRIN GOLD 75/75/20 PO HS 4.T RAMIPRIL 2.5 MG PO OD 5.T CARVIDIOL 3.125 MG PO OD 6.T OROFER XT PO OD 7.INJ HUMAN ACTRAPID INSULIN 6U---6U---6U REFERRED TO HIGHER CENTER I/V/O REQUIREMENT OF VASCULAR SURGEON FOR REVASCULARISATION OF RIGHT LOWER LIMB.

Outcome:GOOD OUTCOME (recovery)

Case 12:.

56,F

SEPTIC ENCEPHALOPATHY (RESOLVING) ?UREMIC ENCEPHALOPATHY (RESOLVING) SEPTIC SHOCK WITH MODS (AKI, ALI) ACUTE RESPIRATORY DISTRESS SYNDROME MULTIFOCAL ATRIAL TACHYCARDIA (RESOLVED) SEPTIC SHOCK(RESOLVED) SECONDARY TO RIGHT LOWER LIMB CELLULITIS TYPE 1 RESPIRATORY FAILURE SECONDARY TO NON CARDIOGENIC PULMONARY EDEMA ?ATYPICAL PNEUMONIA S/P 6 SESSIONS OF HEMODIALYSIS GRADE 3 BEDSORE ?SUBMASSIVE PULMONARY EMBOLISM HTN+ DMCase History and Clinical Findings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

PEDAL EDEMA + TEMP:102F PR:98BPM RR:22CPM BP:80/60MMHG SPO2:90% GRBS:65MG/DL CVS: S1 S2 + NO MURMURS RS:BAE+, NVBS PER ABDOMEN:DISTENDED AND NON TENDER CNS: PT IS DROWSY SPEECH SLURRED NFND Investigation USG ON 24/1/23 IMPRESSION: GRADE 2 FATTY LIVER REVIEW USG ON 28/1/23 IMPRESSION: GRADE 2 FATTY LIVER WITH HEPATOMEGALY GB SLUDGE MESENTERIC LYMPHADENOPATHY HRCT OF THROAX: IMPRESSION: MILD TO MEDERATE PLEURAL EFFUSION WITH BASAL ATELECATASIS FEW NODULAR OPACITIES SEEN IN LEFT LUNG MAINLY IN UPPER LOBE (INFECTIVE ETIOLOGY) HEPATIC STENOSIS 2D ECHO ON 28/1/23 CONCENTRIC LVH + NO RWMA

MILD MR+/AR+ SCLEROTIC AV, NO AS, MS EF=58 GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION +, NO PE IVC SIZE (1.48CMS) HB-6.5-6.3-7.6-7.5-7.3-7.2 TLC-11,800-15,500-13,400-14,900-16,600-14,900 PLATELET-1.80-1.80-1.90-1.96-1.78-1.61 Treatment Given(Enter only Generic Name) NEB. DUOLIN 8TH HOURLY BUDECORT 12TH HOURLY MUCOMIST 12TH HOURLY IV FLUIDS 2 NS @150ML/HR 1 RL @150ML/HR 1 DNS @150ML/HR INJ MEROPENEM 500MG IV BD FOR 7 DAYS INJ LASIX 40MG IV BD INJ PAN 40 MG IV OD INJ ZOFER 4MG IV SOS INJ NEOMOL 1 GM IV SOS (IF TEMP >101F) TAB. DOXY 100MG RT BD FOR FOR 7 DAYS TAB.PIRFENIDONE 200MG RT BD FOR 5 DAYS T. MET-XL 25MG RT OD T.SHELCAL-CT RT OD T.PCM 650MG RT BD T.SPOROLAC-DS RT TID SYP.ASCORYL LS 10ML RT TID RT FEEDS 50L WATER 2ND HRLY , 100ML MILK WITH PROTEIN POWDER 4TH HRLY OINT THROMBOPHOBE GEL L/A BD 3 PRBC TRANSFUSION DONE.

Advice at Discharge NEBULISATION WITH DUOLIN 8TH HRLY NEB BUDECORT 12TH HRLY WITH MUCOMIST 12TH HRLY TAB LASIX 40MG PO BD 8AM-8PM TAB PAN 40 MG PO OD 7AM BEFORE FOOD TAB MET XL 25MG PO OD AT 8AM TAB.PIRFENIDONE 200MG PO BD 8AM AND 8PM T. SHELCAL CT PO OD AT 8AM T. PCM 650MG PO BD AT 8AM AND 8PM T.ZOFER 4MG PO SOS SYP.ASCORYL LS 10ML PO BD AT 8AM AND 8PM THROMBOPHOBE OINTMENTFOR L/A AT 8AM AND 8PM

Pt outcome: Good recovery at discharge,Died after 45 days of follow-up

Case 13:

70 Years Old Man Who was a Farmer By Occupation Presented to Casualty With

Altered Sensorium Since 3 Days

Fever Since 20 Days

HOPI :

Patient Was Apparently Asymptomatic Till 2014 ;

2014 - Patient Had Fever Associated with Cough for which he went to Hospital & Was Diagnosed to Have ? Pneumonia with DENOVO DM2 & Was Prescribed with OHAs ( Tab.METFORMIN & Tab.GLIMIPRIDE )

6 Months Back - Patient Had Fever Associated with Cough for Which he Went to Hospital & Said to Have High Sugars along with Lung Infection ; Got Treated & Discharged in a Hemodynamically Stable Manner.Started using insulin for Diabetes Since Then

20 Days Back : Patient Had Fever with Cough ; For Which He went to Hospital & Suspected to Have TB But Reports Turned out to be Negative & Patient Discharged as LAMA & When He Returned Home 3 Days Back He Gradually Developed Altered Sensorium & Couldn't Recognise His Attendants

Past History :

K/C/O DM2 Since 9 Years and on Regular Medications

N/K/C/O HTN ; TB ; EPILEPSY ; ASTHMA

Addictions :

He Started Consumption of Alcohol at the age of 20years & It became a habit to drink 90ml per Day Till 6 Months Back

He Started Smoking Beedis at the age of 20 Years & It Became a Habit to Smoke 20 Beedis Per Day

On Presentation :

BP - 110/80mmHg

PR - 110/min

Temp - 102.5 F

RR - 22/min

Spo2 - 98% @RA

CVS - S1S2 Heard & No Murmurs

RS - BAE + ; NVBS +

P/A - Soft & Non Tender

CNS -

GCS - E2V2M5

RT Pupil - Couldn't be assessed

Lt Pupil - NSRL

Tone - Normal in Both UL & Hypertonia in Both lower limbs

Power - 4/5 In all 4 Limbs

Reflexes - B T S K A - 2+

Plantars - RT - Mute & Left - Flexor

Investigations -

. Urea-24mg/dl

S creatine-0. 8mg/dl

S. Electrolytes -

Na+-132

K+- 3.6

Cl- 98

Ca2+ 1.20

CSF analysis-

glucose -42

Protein -60

Cl-121

ADA-131

CSF CELL COUNT

Vol-0. 5 ml

Color- colorless

Appearance- clear

Total count-104 cells

DC-

60% lymphocytes

20% monocytes

20% neutrophils

Others- nil

RBC- nil

Provisional diagnosis -

?TB meningitis

Treatment -

Ryles tube feeds-200 ml milk every 4 th hourly

100 ml water every hourly

Iv fluids NS @50 ml/hr

Inj. Ceftriaxone 2 GM iv stat

Then inj . Ceftriaxone 1 GM iv bd

Inj Dexa 6 mg iv stat then

Inj. Dexa 6mg iv tid

Monitor vitals 2 nd hourly

Grbs monitoring

Strict input and output charting

Inj. Neomol 1 GM iv /sos ( if temp>101F).

Pt outcome:

Patient Died in the hospital

Case 14:

46 male,

Diagnosis:

Decompensated liver disease with Hepatic encephalopathy

A 45 YEARS OLD MALE, HOTEL SERVER BY OCCUPANTION CAME WITH COMPLAINTS OF ABDOMINAL DISTENSION AND SHORTNESS OF BREATH AND SWELLING OF BOTH LOWER LIMBS SINCE 1 WEEK HOPI: PATIENT WAS ASYMPTOMATIC,6 YEARS AGO AND THEN HE DEVELOPED A MINOR INJURY TO NECK WHICH WAS NOT HEALING AND THEN WENT FOR REGULAR CHECKUP AND WAS DIAGNOSED AS HAVING DIABETES AND STARTED ON OHA, AND 3 YEARS AGO HE WAS DIAGNOSED TO BE HAVING HYPERTENSION AND STARTED ON TAB. TELMISARTAN 40MG/OD,AND WAS ASYMPTOMATIC 7 MONTHS AGO AND THEN IN THE EVENING HE SUDDENLY BECAME ,UNRESPONSIVE AND IRRELEVANT TALK AND WAS TAKEN TO HOSPITAL AND WAS FOUND TO BE HAVING HYPOGLYCAEMIA AND WAS ASKED TO STOP OHA,AND WAS FOUND TO BE HAVING JAUNDICE AT THAT TIME AND WAS ASKED TO AVOID ALCOHOL BUT HE DIDN’T STOPPED ALCOHOL CONSUMPTION. AND 5 MONTHS AGO,HE DEVELOPED SIMILAR COMPLAINTS AND WAS ADMITTED HERE AND WAS DIAGNOSED TO BE HAVING,ACUTE DECOMPONSATED LIVER DISEASE AND WAS KEPT ON CONSERVATIVE MANAGEMENT, A DIAGNOSTIC AND THERAPEUTIC TAP WAS DONE,SHOWING 200CELLS,LYMPHOCYTIC PREDOMINANT CELLS AND HIGH SAAG AND LOW PROTEIN PROFILE AND THERAPEUTIC PARACENTESIS WAS DONE 1L ON DAY 1

1.75L ON DAY 2 AND 1.5L ON DAY 3 AND HIS COMPLAINTS RESOLVED AND WAS DISCHARGED IN A HEMODYNAMICALLY STABLE STATE,AND WAS NORMAL TILL 15 DAYS AND STARTED DEVELOPING PEDAL EDEMA ,ABDOMINAL DISTENSION AND SOB AGAIN AND CAME HERE FOR FURTHER MANAGEMENT. DECREASED APETITE AND SLEEP SINCE 2 DAYS. CHRONIC ALCOHOLIC SINCE 20 YEARS AND LAST BINGE,30DAYS AGO. CHRONIC SMOKER SINCE 30YEARS PAST HISTORY: K/C/O CLD SINCE 5 MONTHS K/C/O HTN SINCE 2 YEARS K/C/O DM II SINCE 6 YEARS PERSONAL HISTORY: CHRONIC ALCOHOLIC CONSUMES 3 QUARTERS/DAY CHRONIC SMOKER 40 CIGARETTES/DAY (SINCE 30 YEARS) GENERAL PHYSICAL EXAMINATION: AT ADMISSION PATIENT IS DROWSY BUT AROUSABLE, ICTERUS : PRESENT CLUBBING: PRESENT PEDAL EDEMA: PITTING TYPE NO SIGNS OF CYANOSIS, GENERALISED LYMPHADENOPATHY BP 140/80MMHG PR 98BPM RR 18CPM TEMP AFEBRILE SPO2 98% ON RA SYSTEMIC EXAMINATION: CARDIOVASCULAR SYSTEM: S1 AND S2 HEARD. NO MURMURS RESPIRATORY SYSTEM: BAE PRESENT. NVBS HEARD CENTRAL NERVOUS SYSTEM: PATIENT IS DROWSY AND AROUSABLE SPEECH NORMAL NO SIGNS OF MENINGEAL IRRITATION

P/A DISTENDED,AND UMBILICUS EVERTED DILATED VEINS PRESENT OVER THE LOWER ASPECT OF ABDOMEN AND SHIFTING DULLNESS POSITIVE AND FLUID THRILL NEGATIVE. ABDOMINAL GIRTH 124CMS GENITALS EXAMINATION: SCROTAL SWELLING PRESENT Advice at Discharge 1. TAB. LASIX 60 MG IV/BD X 7 DAYS 8AM--X--7PM 2. TAB. TAXIM 200 MG PO/BD X 5 DAYS 3. FLUID RESTRICTION <1.5LIT/DAY 4. SALT RESTRICTION <1.2 GM/DAY 5. TAB. RANTAC 150 MG PO/OD/BBF 6. TAB. ALDACTONE 50 MG PO/OD X 7 DAYS X--X--7PM 7. TAB. TELMISARTAN 40 MG PO/OD 8. SYRUP. LACTULOSE 30 ML PO/TID

Pt outcome:

*Patient was discharged home in a good State

Case 15:

43 female,

Diagnosis GTCS (3 EPISODES ) SECONDARY TO ACUTE ENCEPHALITIS (BACTERIAL>VIRAL)? CEREBRAL MALARIA ,H/O ACUTE GASTROENTERITIS(RESOLVED) WITH AKI SECONDARY TO ATN (NON OLIGURIC) (DRUG INDUCED -ACYCLOVIR , VANCOMYCIN)WITH HYPERTENSION SINCE 3 MONTHS Case History and Clinical Findings PATIENT CAME WITH COMPLAINTS OF FEVER SINCE 1 WEEK, VOMITINGS AND LOOSE STOOLS SINCE 4 DAYS INVOLUNTARY MOVEMENTSOF BOTH UPPER LIMBS AND LOWER LIMBS SINCE 1 DASY HOPI: PATIENT WAS APPARENTL ASYMPTOMATIC 1WEEK BACK, THEN SHE DEVELOPED FEVER OF LOW GRADE INTERMITTENT, RELIEVED ON MEDICATION NOT ASSOCIATED WITH CHILLS AND RIGOR, BURNING MICTURITION, COUGH AND COLD PATIENT HAD VOMITINGS WHICH ARE BILIOUS, NON PROJECTILE, NON BLOOS TINGED, FILLED WITH FOOD PARTICLES(2-3 TIMES PER DAY)

C/O LOOSE STOOLS LOW VOLUME, WATERY CONSISTENCY, NON MCOPURUENT, NON BLOOD TINGED, NO H/O OUTSIDE FOOD CONSUMPTION PATIENT HAD 3 EPISODES OF INVOLUNTARY MOVEMENTS 9RIGIDITY OF BOTH UPPER LIMBS AD LOWER LIMBS) ASSOCIATED WITH UPROLLING OF EYES, INVOLUNTARY MICTURITION, TONGUE BITE AND IS IN POST ICTAL CONFUSION/IRRITABLE SINCE THEN PAST HISTORY: K/C/O HTN SINCE 3 MONTHS(ON IRREGULAR MEDICATION OF UNKNOWN DRUGS) NOT A K/C/O DM, ASTHMA, THYROID DISORDERS, CAD, CVA CHOLECYSTECTOMY DONE 4 YEARS AGO PERSONAL HISTORY:TAKES MIXED DIET, NORMAL APPETITE, BOWEL AND BLADDER HABITS ARE REGULAR ADDICTIONS: OCCASIONALLY TODDY DRINKER MENSTRUAL HISTORY: 3/30 DAYS, REGULAR GENERAL EXAMINATION: PATIENT WAS IRRITABLE NO SIGNSOF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA VITALS: TEMP: 104F BP: 130/90 MMHG PR: 92 BP, RR: 16 CPM SPO2: 95% AT RA GRBS: 211 MG/DL SYSTEMIC EXAMINATION: CVS: S1 S2 HEARD, NO MURMURS RESPIRATORY SYSTEM: BILATERAL AIR ENTRY PRESENT PER ABDOMEN:OBESE, SOFT, NO TENDERNESS, BOWEL SOUNDS HEARD CNS: PATIENT WAS IRRITABLE SPEECH- INCOHERENT MENINGEAL SIGNS- ABSENT COURSE IN HOSPITAL: OPHTHALMOLOGYOPINION WAS TAKEN ON 2/3/23 I/V/O FUNDOSCOPIC CHANGES FOR RAISED ICT: NO FEATURES OF RAISED ICT WERE SEEN IN BOTH EYES ANESTHESIOLOGY REFERRAL WNEUROLOGY OPINION WAS TAKEN ON 2/3/2023 AND ADVISED INJ. VANCOMYSIN 1GM IV/BD FOR 7 DAYS INJ. DOXYCYCLINE 100 MG IV/BD X FOR 3 DAYS INJ. ACYCLOVIR 1GM IV/TID FOR 5 DAYS INJ. DEXA 8MG IV/BD FOR 7 DAYS Investigation HEMOGRAM ON 2/3/23: HB- 11.8 GM/DL, TLC- 12,500 CELLS/CUMM, PLT- 2.35 LAKHS, SMEAR:NORMOCHROMIC NORMOCYTIC BLOOD PICTURE HEMOGRAM ON 3/3/23; HB- 11.8 MG/DL, TLC- 9400 CELLS/CUMM, PLT- 2.05 LAKHS, SMEAR:NORMOCHROMIC NORMOCYTIC BLOOD PICTURE LDH- 331 IU/L M.P STRIP TEST:NEGATIVE BT- 2 MIN. 30SEC CT- 4 MIN C- REACTIVE PROTEIN: NEGATIVE MRI BRAIN: NO ABNORMALITY DETECTED IN BRAIN PARENCYMA DILATED PERIOPTIC CSF SPACES AND EMPTY SELLA 2D ECHO: EF: 65% TRIVIAL AR, NO MR/TR NO RMWA. NO AS/MS GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION. NO PAH/PE Treatment Given(Enter only Generic Name) IV FLUIDS AT 75ML/HR INJ. VANCOMYSIN 1GM IV/BD FOR 7 DAYS INJ. DEXA 8MG IV/BD FOR 7 DAYS INJ. MONOCEF 2GM IV/BD FOR 7 DAYS INJ. DOXYCYCLINE 100 MG IV/BD X FOR 3 DAYS INJ. ACYCLOVIR 1GM IV/TID FOR 5 DAYS INJ. FALCIGO 120 MG IV INJ. PCM 1GM IV/TID FOR 2 DAYS INJ. PAN 40 MG IV/OD INJ. LEVIPIL 500 MG IV/BD FOR 4 DAYs

INJ. OPTINEURON 1 AMPIN 100ML NS TAB. LEVIPIL 500MG PO/BD FOR 2 DAYS TAB. ATENOLOL 50MG+ TAB. AMOLODIPINE 5 MG PO/OD Advice at Discharge TAB. LEVIPIL 500MG PO/BD TAB. ATENOLOL 50MG+ TAB. AMOLODIPINE 5 MG PO/OD

*Patient outcome:. Discharged with good recovery*

Case 16:

39 M

WERNICKES ENCEPHALOPATHY WITH ALCOHOL DEPENDENCE SYNDROME ACUTE CVAACUTE LOBAR HEMORRHAGE IN RIGHT FRONTAL LOBE CAUSING MASS EFFECT ON THE VENTRICLES WITH SUBFALCINE HERNIATION TO RIGHT SIDE AND MIDLINE SHIFT OF 10 MM.ACUTE HEMORRHAGE IN RIGHT ANTERIOR TEMPORAL LOBEBOTH THE ABOVE HEMATOMAS ARE SURROUNDED BY EXTENSIVE PERILESIONAL EDEMATHIN LAYER OF SUBDURAL HEMORRHAGE IN RIGHT FRONTAL AND LEFT OCCIPITAL REGIONDIFFUSE CEREBELLAR PALSY Case History and Clinical Findings CHIEF COMPLAINTS; PATIENT WAS BROUGHT WITH CHIEF COMPLAINT OF UNABLE TO STAND AND EAT ON HIS OWN SINCE 20 DAYS URINARY INCONTINENCE SINCE 15 DAYS HISTORY OF PRESENT ILLNESS; PATIENT WAS APPARENTLY NORMAL 20 DAYS BACK THEN SUDDENLY DEVELOPED INABILITY TO STAND ON HIS OWN AND ALSO INAILITY TO EAT ON HIS OWN GRADUALLY PROGRESSIVE INITIALLY PATIENT USED TO DO HIS OWN ACTIVITIES BUT GRADUALLY STOPPED DOING HIS WORK AND GOT BED RIDDEN

C/O URINARY INCONTINENCE SINCE 15 DAYS BEFORE THAT PATIENT INFORMED ABOUT HIS URINATION BUT SINCE 15 DAYS HE IS PASSING URINE INVOLOUNTARILY ATTENDERS ALSO COMPLAIN OF PATIENT SELF TALKING AND ALSO PATIENT POINTING ONTO SOMETHING AND TALKING[HALLUCINATIONS-VISUAL] NO H/O FEVER ,SOB,CHEST PAIN,PAIN ABDOMEN SLURRING OF SPEECH SINCE 15 TO 20 DAYS,LAST ALCOHOL BINGE 20 DAYS BACK H/O SIMILAR COMPLAINTS IN THE PAST IN NOV 2022,HE WAS TAKEN TO A LOCAL HOSPITAL 6 TO 7 YEARS BACK STAYED FOR 2 MONTHS AND STARTED CONSUMING ALCOHOL AGAIN 15 DAYS AFTER DISCHARGE PAST HISTORY; N/K/C/O DM2,HTN,TB,EPILEPSY,CVA,CAD,THYROID DISORDERS FAMILY HISTORY; INSIGNIFICANT GENERAL EXAMINATION; PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE WELL ORIENTED TO TIME,PLACE AND PERSON MODERATELY BUILT AND MODERATELY NOURISHED NO PALLOR,CYANOSIS,CLUBBING,LYMPHADENOPATHY AND PEDAL OEDEMA VITALS;Bp -120/80mmhgPR -72 bpm ;RR : 16cpmSpo2 : 98 on RACNS examination:SYSTEMIC EXAMINATION:CENTRAL NERVOUS SYSTEM;CNS:LEVEL OF CONSCIOUSNESS ;CONSCIOUSSPEECH;NORMALNO SIGNS OF MENINGEAL IRRITATIONSENSORY SYSTEM NORMAL CARDIOVASCULAR SYSTEM:S1 S2 heardNo murmurs.RESPIRATORY SYSTEM:Dyspnea- NoNo wheezeBreath sounds - vesicularNo Adventitious soundsABDOMINAL EXAMINATION:-No tendernessNo palpable liver and spleen.Bowel sounds - present. Investigation FBS;138 MG/DL T3; HB;12.4 GM/DL TC;5,200 NEUTROPHILS;55% LYMPHOCYTES;34% EOSINOPHILS;06% MONOCYTES;05% BASOPHILS;00% PCV;38.7 VOL%

MCV 87.6 MCH;28.1 MCHC;32.0% RBC COUNT:4.4 MILLIONS/CUMM PLATELET COUNT;3.2 LAKHS/CUMM IMPRESSION;NORMOCYTIC NORMOCHROMIC BLOOD PICTURE USG DONE ON 02/03/2023 IMPRESSION;GRADE I TO II FATTY LIVER 2D ECHO DONE ON 03/03/2023 IMPRESSION;EF- 64% IVC-0.57CMS[COLLAPSING] MILD AR+,TRIVIAL TR+,NO MR NO RWMA,NO AS/MS GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION,NO PAH/PE PSYCHIATRY REFERRAL TAKEN I/V/O ALCOHOLIC DEPENDENCE SYNDROME. ADVISED; 1.TAB.CHLORDIAZEPOXIDE 25 MH PO/BD 2.TAB.LORAZEPM 2MG PO/SOS[IF PT IRRITABLE/RESTLESS/AGITATED AND STOP IF PT IS DROWSY] 2.TO CONTINUE TO THIAMINE SUPPEMENTATION 3.ADEQUATE HYDRATION 4. VITALS AND ORIENTATION MONITORING 4TH HOURLY NEURO SURGERY REFERRAL TAKEN I/V/O ACUTE HEMORRHAGE IN BRAIN AND THEIR ADVISE FOLLOWED MRI DONE ON 04/03/2023 ACUTE LOBAR HEMORRHAGE IN RIGHT FRONTAL LOBE CAUSING MASS EFFECT ON THE VENTRICLES WITH SUBFALCINE HERNIATION TO RIGHT SIDE AND MIDLINE SHIFT OF 10 MM.ACUTE HEMORRHAGE IN RIGHT ANTERIOR TEMPORAL LOBEBOTH THE ABOVE HEMATOMAS ARE SURROUNDED BY EXTENSIVE PERILESIONAL EDEMATHIN LAYER OF SUBDURAL HEMORRHAGE IN RIGHT FRONTAL AND LEFT OCCIPITAL REGIONDIFFUSE CEREBELLAR PALSY Treatment Given(Enter only Generic Name) 1)INJ.THIAMINE 200 ML IN 100 ML NS.I.V/TID

2)INJ.OPTINEURON 1 AMP IN IN 100 ML NS.I.V/TID@8AM,2PM,8PM 3)I.V FLUIDS 1 NS 1 RL@ 100 ML/HOUR 4)INJ.MANNITOL 100 ML I.V/TID 5)TAB.CHLORDIAZEPOXIDE 250 MG PO/BD 6]TAB.LORAZEPAM 2MG PO/SOS 7]GRBS MONITORING 4TH HOURLY 8]VITALS MONITORING 4 TH HOURLY Advice at Discharge PATIENT IS GETTING DISCHARGED FOR ADMINISTRATIVE PURPOSE TRANSFERRING THE CASE TO NEUROSURGERY DEPARTMENT Follow Up REVIEW TO MEDICAL OPD AFTER 10 DAYS OR SOS

Patient outcome:

Patient outcome is good/good recovery

Case 17:

53M

ALTERED SENSORIUM SECONDARY TO ?TRUE HYPONATREMIA (HYPOVOLEMIC) SECONDARY TO GI LOSSES INVOLUNTARY MOVEMENTS (? POLYMYOCLONUS) SECONDARY TO ? HYPOVOLEMIC HYPONATREMIA[RESOLVED] WITH HTN SINCE 5YEARS Case History and Clinical Findings 52YEAR OLD MALE CAME WITH THE CHIEF COMPLAINTS OF GIDDINESS SINCE 3 DAYS VOMITINGS 2 DAYS BACK LOOSE STOOLS 2 DAYS BACK INVOLUNTARY MOVEMENTS OF BILATERAL UPPER LIMBS SINCE YESTERDAY MORNING HOPIPATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO THEN HE DEVELOPED GIDDINESS , SUDDEN IN ONSET , MORE ON STANDING AND LATER PROGRESSED TO GIDDINESS ON SUPINE POSITION

VOMITINGS 2 DAYS AGO 3 TO 5 EPISODES /DAY FOOD PARICLES AS CONTENTS, NON BILIOUS, PROJECTILE AND NON BLOOD STAINED LOOSE STOOLS 2 DAYS AGO ABOUT 3 TO 5 EPISODES PER DAY NON BULKY, NON FOUL SMELLING INVOLUNTARY MOVEMENTS OF HANDS AND FINGERS SINCE MORNING NO H/O LOSS OF CONSCIOUSNESS, UPROLLING OF EYES, INVOLUNTARY MICTURITION OR DEFECATION AND HEADACHE PAST H/OK/C/O HTN, SINCE 5 TO 6 YEARS AND ON MEDICATION TELMISARTAN 40 MG PAST H/O CVA PRESENT 2 YEARS BACK NOT A K/C/O DM,TB, ASTHMA, EPILEPSY, THYROID DISORDERS, CVA OR CAD ON GENERAL PHYSICAL EXAMINATIONPATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE ON VITALSBP-- 130/90 MMHG PR- 96 BPM RR- 20 CPM TEMP- 96.8 F SPO2- 975 ON RA GRBS- 117 MG/DL THERE IS NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY AND EDEMA SYSTEMIC EXAMINATIONCVS- S1,S2 PRESENT, NO MURMURS RS EXAMINATION- BAE PRESENT, POSITION OF TRACHEA -0 CENTRAL, NORMAL VESICULAR BREATH SOUNDS PRESENT P/A EXAMINATION- SHAPE OF ABDOMEN- SCAPHOID, BOWEL SOUNDS - PRESENT CNS EXAMINATION- HIGHER MENTAL FUNCTIONS - INTACT PUPILS- B/L NORMAL IN SIZE, REACTIVE TO LIGHT SENSORY SYSTEM EXAMINATION-- COULDN'T BE ASSESSED MOTOR SYSTEM EXAMINATION

TONE RIGHT LEFT UPPER LIMB NORMAL NORMAL LOWER LIMB NORMAL NORMAL POWER UPPER LIMB 5/5 5/5 LOWER LIMBS 5/5 5/5 REFLEXES RIGHT - BICEPS - TRICEPS - SUPINATOR - KNEE - ANKLE - PLANTAR- EXTENSION LEFTBICEPS - TRICEPS - SUPINATOR - KNEE - ANKLE - PLANTARS- EXTENSION COURSE IN THE HOSPITAL52YEAR OLD MALE CAME WITH THE CHIEF COMPLAINTS POF GIDDINESS SINCE 3 DAYS VOMITINGS 2 DAYS BACK LOOSE STOOLS 2 DAYS BACK INVOLUNTARY MOVEMENTS OF BILATERAL UPPER LIMBS SINCE YESTERDAY MORNING AND HE WAS TREATED WITH IV FLUIDS 0.9 5 NS T 75 ML/HR

INJ. OPTINEURON 1 AMP IN 100 ML NS/ IV/OD INJ. PAN 40 MG IV/OD INJ. METROGYL 500 MG IV/ TID INJ. ZOFER 4 MG IV/ BD TAB. OROFER OZ 200/500 MG PO/OD DAY- 1C/O SOB AND IRRITABLE BEHAVIOUR STOOLS PASSED YESTERDAY NIGHT INVOLUNTARY MOVEMENTS DECREASED COMPARED TO PREVIOUS DAY AND CONTINUED WITH THE SAME TREATMENT WITH ADDITION OF INJ. CIPROFLOXACIN 200 MG IV/ BD I/V/O INCREASED TLC? INJ. 3 PERCENT NS AT 10 ML/HR NEBULISATION WITH IPRAVENT AND BUDECORT 8TH HOURLY DAY-2 FEVER SPIKE PRESENT YESTERDAY NIGHT STOOLS NOT PASSED INVOLUNTARY MOVEMENTS DECREASED COMPARED TO PREVIOUS DAY AND CONTINUED THE SAME TREATMENT WITH ADDITION OF UDILIV 300MG PO/BD DAY 3 STOOLS NOT PASSED INVOLUNTARY MOVEMENTS DECREASED COMPARED TO PREVIOUS DAY AND CONTINUED THE SAME TREATMENT DAY 4 PATIENT IS CONCIOUS COHERENT AND COOPERATIVE ON VITALSBP-- 130/90 MMHG PR- 96 BPM RR- 20 CPM TEMP- 96.8 F SPO2- 97% ON RA.

GRBS- 117 MG/DLSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 31-032023 07:36:PMSODIUM132 mEq/L145-136 mEq/LPOTASSIUM3.2 mEq/L5.1-3.5 mEq/LCHLORIDE99 mEq/L98-107 mEq/LCALCIUM IONIZED1.06 mmol/L PATIENT WAS DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION Investigation MRI REPORTOLD LACUNAR INFARCT IN LEFT LENTIFORM NUCLEUS 2D ECHOEF- 65% RWSP- 38 MMHG NO RWMA MILD LVH PRESENT TRIVIAL TR/AR PRESENT, NO MR GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION PRESENT, NO PAH/PE IVC SIZE 1.20 CM HEMOGRAM 29/03/23 30/03/23 31/03/23 HB- 13.6 G/DL 12.9 13 TLC-19000 12500 10100 PCV-35.1 33.5 35 RBC-4.67 4.35 4.48 PLT-2.87L 2.38 2.73 Treatment Given(Enter only Generic Name) IV FLUIDS 0.9 % NS AT 75 ML/HR INJ. OPTINEURON 1 AMP IN 100 ML NS/ IV/OD INJ. PAN 40 MG IV/OD INJ. METROGYL 500 MG IV/ TID( 4 DAYS) INJ. ZOFER 4 MG IV/ BD INJ. CIPROFLOXACIN 200 MG IV BD X 3 DAYS NEBULISATION WITH IPRAVENT AND BUDECORT 8TH HOURLY

Advice at Discharge TAB CIPROFLOXACIN 500MG PO/BD X 2 DAYS TAB. METROGYL 400 MG PO/ TID X 2 DAYS TAB PAN 40MG PO/OD/BBF X 1 WEEK TAB UDILIV 300MG PO/BD X 1 WEEK TAB MVT PO/OD X 1 WEEK SYP POTKLOR 10ML PO/TID X 1 WEEK

Patient outcome: Discharged with good recovery

Case 17:

53M

Patient outcome: Discharged with good recovery

.Case 18:

46,M

HEPATIC ENCEPHALOPATHY

ACUTE ON CHRONIC DECOMPENSATED LIVER DISEASE, NORMOCYTIC NORMOCHROMIC ANEMIA [HYPOPROLIFERATIVE] WITH ANEMIA OF CHRONIC DISEASE HRS-CHRONIC KIDNEY DISEASE? DIABETIC NEPHROPATHY WITH ?PORTO PULMONARY HTN Case History and Clinical Findings C/O ABDOMINAL DISTENSION SINCE 4 MONTHS ON AND OFF SHORTNESS OF BREATH SINCE 4MONTHS HISTORY OF PRESENTING ILLNESSPATIENT WAS APPARENTLY ASYMOTOMATIC 4 MONTHS AGO THEN HE STARTED C/O ABDOMINAL DISTENSION WHICH WAS DISTENSION WHICHWAS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE SINCE 1 MONTH ABDOMINAL DISTENSION IS PROGRESSIVE IN NATURE FOR WHICH HE VISITED GANDHI HOSPITAL AND WAS DIAGNOSD AS ALD WITH PORTAL HTN WITH DECOMPENSATED LIVER LIVER DISEASE WITH HEPATIC ENCEPHALOPATHY GRADE 1 WITH RT PLEURAL EFFUSION -MILD.

PEDAL EDEMA SINCE 4 MONTHS INSIDIOUS IN ONSET GRADUALIIY PROGRESSIVE ,RELIEVED AT NIGHT ,AGGRAVATED IN THE MORNING [PITTING EDEMA] -SOB DUE TO ABDOMINAL DISTENSON , PRESENT EVEN ON REST ORTHOPNEA AND PND PRESENT NO CHEST PAIN,PALPITATION. C/O DECREASED URINE OUTPUT SINCE 1 MONTH PATIENT IS ON FOLEYS CATHETER SINCE THEN-K/C/O DM 2 SINCE 15 YEARS-OPERATED FOR ILIOPSOAS ABSCESS [10MONTHS AGO] TREATMENT HISTORYINJ.MIXTARDBD FOR DM2 SURGERY FOR ILIOPSOAS ABSCESS PERSONAL HISTORYPERSONAL HISTORY: DIET-MIXED APPETITE -NORMAL BOWEL AND BLADDER - REGULAR SLEEP-ADEQUATE ADDICTIONS- REGULAR INTAKE SINE 15 YEARS ,10 DATS AGO PATIENT CONSUMED ALCHOL CONTINOUSLY ALLERGIES- NONE FAMILY HISTORY: INSIGNIFICANT GENERAL EXAMINATION: PATIENT IS CONSIOUS ,COHERNT ,COPERATIVE NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY VITALS: TEMP-AFEBRILE BP- 110/70MMHG RR-18CPM GRBS-125 MG/DL SPO2-99% AT ROOM AIR Page-2 SYSTEMIC EXAMINATION:

CVS-S1 S2 HEARD NO MURMURS CNS-NAD RS-BAE+ NVBS P/A -DISTENDED,SOFT NON TENDER,NO GUARDING,NO RIGIDITY, HERNIAL ORIFICES NORMAL. COURSE IN THE HOSPITALPATIENT IS A KNOWN CASE OF CHRONIC DECOMPENSATED LIVER DISEASE SINCE 4 MONTHS WITH ASCITES .HE IS ON REGULAR MEDICATION FOR SAME SINCE 4-5 DAYS THE ASCITES HAS AGGRAVATED AND PATIENT CAME FOR FURTHER EVALUATION.USG ABDOMEN REVEALED GROSS ASCITES AND CIRRHOSIS OF LIVER.ON THOROUGH CLINICAL,LABORATORY AND RADIOLOGICAL INVESTIGATION PATIENT HAS GROSS ASCITES OF 4-5 LITRES. THE WEIGHT OF PATIENT WAS 69KGS AND ABDOMINAL GIRTH WAS 89 CMS.DIAGNOSTIC ASCITIC TAP DONE.-SHOWED HIGH SAAG AND LOW PROTEIN.THERAPEUTIC TAP OF 700ML DONE.INJ.ALBUMIN 20 PERCENT GIVEN OVER 1 HOURINITIALLY HAD LOW URINE OUTPUT AFTER ADDING LOW DOSE SPIRONOLACTONE PATIENTS URINE OUTPUT IMPROVED. NEPHROLOGY OPINION TAKEN AND DIAGNOSED AS CKD.ADVISED FOR CONSERVATIVE MANAGEMENT . TREATMENT: FLUID RESTRICTION LESS THAN 2.5 LIT/DAY TAB.NODOSIS 500MG PO BD TAB.OROFER XT PO OD TAB.SHELCAL 500MG PO OD DERMATOLOGY OPINION TAKEN FOR DIFFUSE XEROSIS OVER BILATERAL FOREARM.MULTILE HYPERPIGMENTENTED MACULES NOTED ON PALMS ALONG WITH ITCHING WAS DIAGNOSED AS PRURITIS SECONDARY TO CHRONIC LIVER DISEASE.ACQUIRED DICTHYOSIS.ADVICED LIQUID PARAFFIN BD FOR 2 WEEKS.OPHTHALMOLOGY OPINION TAKEN FOR DIABETIC RETINOPATHY CHANGES. IMP:RIGHT EYE NPDR LEFT EYE PDR NOTED ADVICED FOR GLYCEMIC CONTROL AND REVIEW TO OPD ON THURSDAY FOR RETINA SPECIALIS ON 30/05/2023 WEIGHT:71 KG ABDOMINAL GIRTH:92 CM AFTER TAP ----. 89CM ,WT -----.68KG. 2.5 LIT ASCITIC TAP DONE AND INJ.ALBUMIN 20 PERCENT GIVEN OVER 1 HR AND SYMPTOMS OF SOB AND ABDOMINAL DISCOMFORT REDUCED.PRBC TRANSFUSION DONE I/V/O SEVERE ANEMIA HB:6GM/DL.AFTER TRANSFUSION HIS HB WAS 8.7GM/DL.

GASTROENTEROLOGY OPINION TAKEN.ADVICED LARGE VOLUME PARACENTESIS ALONG WITH 2 ALBUMIN TRANSFUSION ON DAY OF PARACENTESIS REFERRED TO HIGHER CENTER-- PATIENT AND PATIENTR ATTENDERS HAVE BEEN EXPLAINED ABOUT THELARGE VOLUME PARACENTESIS ALONG WITH 2 ALBUMIN TRANSFUSION ON DAY OF PARACENTES NEED FOR LIVER TRANSPLANTATIO REFERRAL ,AS THE PATIENT IS AN IDEAL CANDIDATE FOR LIVER TRANSPLANTATION AS ADVISED BY THE GASTROENTEROLOGIST AND THE SAME HAS BEEN EXPLAINED TO THE PATIENT AND PATIENT ATTENDER .AND WAS ADVISED TO MEET THE LIVER TRANSPLANTATION TEAM Investigation HAEMOGRAM 28/4/23, 29/4/23 30/4/23 01/5/23 HB:6.0 ,6.1, 5.9, 8.7, TLC:4700, 4800, 4500, 6300 PLATELET 1.65L 1.51L 1.88L 2.94 PCV:18.7 18.2, 18.2 26.1 ASCITIC FLUID - SUGAR - 104 PROTEIN - 1.2 LDH - 140 CELL COUNT - 50CELLS/CUMM , 100% LYMPHOCYTES AND CLEAR. CYTOLOGY REPORT SPECIMEN : ASICTIC FLUID CYTOLOGY MICROSCPY: CYTOMEAR STUDIED SHOWS SCATTERED LYMPHOCYTES FEW MESOTHELIAL CELLS AGAINST PROTEINACEUS BACKGROUND IMPRESSION: NEGATIVE FOR MALIGNANCY 2D ECHO: EF-60% MILD TR ;TRIVIAL MR ;NO AR NO RWDA ,NOAS/MS GOOD LV SYSTOLIC FUNCTIUON DIASTOLIC DYSFUNCTION ,NO PAH Treatment Given(Enter only Generic Name)

TAB.SPROINOLACTONE 25MG/PO/OD TAB.RIFAGUT 550MG PO/BD TAB.UDILIV 300MG PO/BD SYP.LACTULOSE 15ML PO TID TAB.LASILACTONE 5/25 PO/OD SYP. HEPAMERZ 15ML PO/BD TAB PAN 40 MG PO/OD BBF FLUID RESTRICTION (2L/D) SALT RESTRICTION (2G/D) IV FLUIDS NS @ OUTPUT +30 ML/HR PROTEIN POWDER 2TBSPS IN 1 GLASS OF WATER /PO/TID INJ.VIT K IM Advice at Discharge REFERRED TO HIGHER CENTER-- PATIENT AND PATIENTR ATTENDERS HAVE BEEN EXPLAINED ABOUT THE NEED FOR LIVER TRANSPLANTATION REFERRAL ,AS THE PATIENT IS AN IDEAL CANDIDATE FOR LIVER TRANSPLANTATION AS ADVISED BY THE GASTROENTEROLOGIST AND THE SAME HAS BEEN EXPLAINED TO THE PATIENT AND PATIENT ATTENDER .AND WAS ADVISED TO MEET THE LIVER TRANSPLANTATION TEAM..

Patient outcome:

Is in encephalopathy during discharge and later lost of follow-up.

Case 19:

67 ,M

ALTERED SENSORIUM SECONDARY TO ALCOHOL INTOXICATION. Case History and Clinical Findings PATIENT CAME WITH C/O OF SLURRED SPEECH 4PM ON 5/08/2023 C/O RIGHT UPPER LIMB &LOWER LIMB WEAKNESS SINCE 4PM. PATIENT PRESENTED TO CASUALITY WITH ALTERED SENOSIRUM SINCE 4PM HOPI: PATIENT HAS A H/O SLURRED SPEECH AND H/O RIGHT UPPER LIMB AND LOWER LIMB WEAKNESS SINCE THEN ASSOCIATED WITH FALL. NO LOC, NO ENT BLEED NO H/O FEVER, BURNING MICTURITION, LOOSE STOOLS NO H/O SOB, PALPITATIONS, ORTHOPNEA, PND HISTORY OF PAST ILLNESS: NOT A K/C/O HTN,DM,EPILEPSY, THYROID DISORDERS. O/E: GCS-E5 V4 M5 BP- 90/60MMHG PR- 68BPM CVS- S1S2 + RS- NVBS +

SPO2- 97% ON RA CNS TONE: RIGHT LEFT UL INCREASED INCREASED LL INCREASED INCREASED POWER: UL &LL COULDNT ELICIT REFLEXES: B +++ ++ T + + S + + K - + A - P FLEX FLEX PUPILS- B/L CONSTRICTED, SLUGGISH REACTIVE COURSE OF ADMISSION: PATIENT WAS ADMITTED I/V/O ABOVE MENTIONED COMPLAINTS. NECESSARY INVESTIGATIONS WERE DONE. MRI FINDINGS- ACUTE INFARCT IN LEFT CAUDATE AND LEFT LENTIFORM NUCLEUS (MCA TERITORY) AGE OF INFARCT 16-24HRS ON CLINICAL EXAMINATIONCNS - TONE: RIGHT LEFT UL INCREASED INCREASED LL INCREASED INCREASED POWER: UL &LL COULDNT ELICIT RELEXES: B +++ ++ T + + S + + K - + A - P FLEX FLEX PUPILS- B/L CONSTRICTED, SLUGGISH REACTIVE

DIAGNOSED AS ALTERED SENSORIUM SECONDARY TO ALCOHOL INTOXICATION. CNS EXAMINATION ON 11/08/2023 TONE: RIGHT LEFT UL INCREASED NORMAL LL INCREASED NORMAL POWER: UL 3/5 4/5 LL 3/5 4/5 RELEXES: B +++ +++ T ++ ++ S + + K +++ ++ A ++ P EXTENSOR EXTENSOR. THE PT WAS MANAGED CONSERVATIVELY &WAS DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION. Investigation HEMOGRAM- HB: 16.8G/DL TC: 9,700 NEUTROPHILS: 67 LYMPHOCYTES: 18 MCH: 33.8 RDW-CV: 16.0 PLATELET: 2.35 LAKHS/CU.MM LFTTB: 1.82 DB: 0.52 ALP: 151 TP: 6.0 ALBUMIN: 3.31 A/G RATIO: 1.23 RFT

UREA: 23 CREATININE: 1.3 URIC ACID: 6.9 CALCIUM: 9.8 PHOSPHORUS: 2.2 SODIUM: 131 POTASSIUM: 3.6 CHLORIDE: 99 Treatment Given(Enter only Generic Name) ON ADMISSION: 1. IV FLUIDS 2.NS @ 75ML/HR, 1.RL 2. INJ THIAMINE 200MG IN 100ML NS IV/BD 3. TAB CASPRIN 75MG + CLOPIDOGREL 75MG + ATORVOSTAIRIN 10MG 4. PHYSIOTHERAPY FOR TIGHT UPPER AND LOWER LIMBS 5. NICOTINE GUMS PO/BD Advice at Discharge 1 TAB. THIAMINE 100 MG PO/BD X 7 DAYS 2. NICOTINE GUMS PO/BD X 7 DAYS 3. T. BACLOFEN XL 20 MG PO/OD X 7 DAYS 4. T.ECOSPRIN -GOLD PO/HS

Patient outcome:

Good recovery at the time of discharge

Case 20:

17/M

Diagnosis ALTERED SENSORIUM SECONDARY TO ALCOHOL INTOXICATION (RESOLVED) Case History and Clinical Findings C/O ALTERED SENSORIUM SINCE 7:30 PM ON 8/8/23 C/O 2-3 EPISODES OF VOMITING SINCE 7:30PM PATIENT WAS APPARENTLY ASYMPTOMATIC TILL TODAY MORNING PATIENT HAD CONSUMED ALCOHOL (5 BEERS) AND PATIENT WAS ALTERED SENSORIUM SINCE 7:30 PM IN THE NIGHT PAST HISTORY: N/K/C/O DM-II,HTN,CVA,CAD,TB,ASTHMA,EPILEPSY GENERAL EXAMINATION PATIENT WAS UNCONCIOUS AT PRESENTATION. GCS SCORE E1V1M4 NO PALLOR,ICTERUS,CYANOSIS,LYMPHADENOPATHY,CLUBBING,PEDAL EDEMA VITALS: TEMP:AFEBRILE PR : 96 BPM

RR 18 CPM BP 60/40 MM HG SPO2 99 GRBS 119 MG/DL PSYCHIATRY OPINION WAS TAKEN AND PATIENT IS COUNSELLED AND PSYCHOTHERAPY IS DONE. AND HARMFUL EFFECTS OF ALCOHOL IS EXPLAINED Investigation ABG PH 7.297 PCO2 40.5 PO2 113 HCO3 19.2 RFT UREA 19 CREATININE 0.8 URIC ACID 6.8 NA 132 K 3.3 CL 102 CA 9.8 HEMOGRAM HB 13.9 TLC 14300 N/L/E/M/B 86/10/1/3/O PCV 41.1 MCV 75.3 MCH 25.6 MCHC 33.9 RBC 5.45 PLT 2.73 FBS 95

Treatment Given(Enter only Generic Name) 1.IV FLUIDS NS@ 100 ML 2.INJ. THIAMINE 800 MG IN 500 ML NS IV STAT 3.TAB. THIAMINE 100 MG PO/BD Advice at Discharge TAB. THIAMINE 100 MG PO/BD X 10 DAYS COMPLETE ABSTINANCE FROM ALCOHOL Follow Up REVIEW SOS

Patient outcome:

Good recovery at discharge

Case 21:

46,M

ACUTE DECOMPENSATED LIVER DISEASE SECONDARY TO ALCOHOL WITH GRADE 2 HEPATIC ENCEPHALOPATHY Case History and Clinical Findings C/O DRAGGING TYPE OF PAIN OF B/L LOWER LIMBS SINCE EVENINGDECREASED URINE OUTPUT SINCE 15 DAYSABDOMINAL DISCOMFORT SINCE 15 DAYSC/O SWELLING OF BILATERAL LOWER LIMBS SINCE 15 DAYSPATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS AGO AND THEN DEVELOPED SWELLING OF BOTH LOWER LIMBS, INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, AND ABDOMINAL DISTENSION SINCE 15 DAYSABDOMINAL DISCOMFORT SINCE 15 DAYSC/O DECREASED URINE OUTPUT SINCE 15 DAYSH/O SEIZURES, 3 EPISODES- ONE IN DEC 2021, JAN 2022, SEP 2022NOT USED ANY MEDICATIONTONIC SEIZURES, UPROLLING OF EYES +, FROTHING FROM MOUTH +POSTURAL CONFUSION + FOR 15 MINUTESSPONTANEOUS URINATION -SPONTANEOUS DEFECATION -VOMITINGS -LOOSE STOOLS -INCREASED DAYTIME SLEEPINESS SINCE 1 WEEKH/O INCREASED BILIRUBIN LEVELS 1 MONTH BACKHYPERPIGMENTED PATCHES (DIFFUSE) PRESENT OVER THE BODYPAST HISTORYNOT A KNOWN CASE OF HTN, DM, ASTHMA, TB, EPILEPSYPERSONAL HISTORYDIET- MIXEDAPPETITE- NORMALBOWEL AND BLADDER MOVEMENTS- REGULARSLEEP- ADEQUATEADDICTIONS- CHRONIC ALCOHOLIC SINCE 20 YEARSFAMILY HISTORYNO SIGNIFICANT FAMILY HISTORYGeneral examinationDone after obtaining consent, in the presence of attendant with adequate exposurePatient is conscious, coherent, cooperative and well oriented to time, place and personPatient is well nourished and moderately builtVitalsTemperature- AfebrileBlood pressure- 90/70 mmHgPulse rate- 82 bpRespiratory rate- 18 cpmSPO2- 98%GRBS- 126 mg%SYSTEMIC EXAMINATIONLocal examinationAbdominal examination:InspectionShape of the abdomen- DistendedUmbilicusevertedMovements of abdominal wall- moves with respirationSkin is smooth, shinyNo visible peristalsis, pulsations, sinuses, engorged veins, hernial sitesPalpationInspectory findings are confirmedFluid thrill positiveAbdominal girth at the level of umbilicus is maximumPercussionFluid thrill- feltAuscultationBowel sounds are decreasedCardiovascular system examination:S1 and S2 sounds are heardNo murmursRespiratory system examination:Bilateral air entry presentNormal vesicular breath sounds are heardCentral nervous system examination:No focal neurological deficitsDEATH SUMMARYA 44 YEARS OLD MALE, CAME TO CASUALTY WITH COMPLAINTS OF ABDOMINAL DISCOMFORT SINCE 15 DAYS, DECREASED URINE OUTPUT SINCE 15 DAYS AND DRAGGING TYPE OF PAIN OF BILATERAL LOWER LIMBS SINCE EVENINGINITIAL INVESTIGATIONS WERE DONE AFTER CLINICAL EXAMINATION OF THE PATIENT AND PATIENT WAS DIAGNOSED WITH ACUTE DECOMPENSATED LIVER DISEASE, SECONDARY TO ALCOHOL GRADE 2 HEPATIC ENCEPHALOPATHY WITH AKI SECONDARY TO RIGHT LOWER LIMB CELLULITIS, AND MANAGED SYMPTOMATICALLY AND RYLES TUBE WAS PLACED AND DIAGNOSTIC ASCITIC TAP WAS DONEAT 2:00 PM, HIS BP WAS NOT RECORDABLE AND PATIENT WAS STARTED ON IONOTROPES TO MAINTAIN BP, BUT STILL HIS BP WASN'T MAINTAINED EVEN ON TRIPLE IONOTROPIC SUPPORT AND AROUND 5:00 PM, ABG WAS DONE SHOWING SEVERE METABOLIC ACIDOSIS, AND BICARBONATE CORRECTION WAS GIVEN, BUT STILL ACIDOSIS IS PERSISTING AND AROUND 9:00 PM, PATIENT HAS BEEN INTUBATED IN VIEW OF FALLING GCS AND FALLING SATURATIONSPOST INTUBATION VITALS: HIS BP IS NOT RECORDABLE AND HIS PULSE RATE IS AROUND 120 BPMPATIENT GRADUALLY DEVELOPED BRADYCARDIA AND SUDDENLY WENT INTO CARDIAC ARREST, FOLLOWED BY WHICH CPR WAS DONE FOR 30 MINUTES, ACCORDING TO AHA GUIDELINES, FOLLOWED BY WHICH PATIENT COULDNOT BE REVIVED AND DECLARED DEAD AT 10:25 PM ON 29/10/22 AS A FLAT LINE WAS OBSERVED ON ECGCAUSE OF DEATHIMMEDIATE CAUSE OF DEATHREFRACTORY HYPOTENSION SECONDARY TO SEPSISANTECEDENT CAUSE OF DEATHSEPSIS WITH MODS, RIGHT LOWER LIMB CELLULITISACUTE DECOMPENSATED CHRONIC LIVER DISEASE, ?ESOPHAGEAL VARICEAL BLEEDINGAKI SECONDARY TO SEPSIS WITH GRADE 2 HEPATIC ENCEPHALOPATHY Investigation 1. CHEST XRAY PA VIEW- NO ABNORMALITY DETECTED 2. ECG- NO ABNORMALITY DETECTED 3.USG- MILD SPLENOMEGALY GROSS ASCITES RIGHT RENAL CALCULUS GB SLUDGE GRADE 1 FATTY LIVER 4. 2D ECHONO RWMA MODERATE TR+ WITH PAH (ECCENTRIC TR+) MLD AR+ MODERATE MR + (ECCENTRIC MR +)

NO AS/MS IAS- INTACT EF- 62 RVSP- 45+10 = 55 MMHG GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION NO PE IVC SIZE (1.68 CMS) DILATED DILATED L.A/R.A/R.V/IVC Treatment Given(Enter only Generic Name) TREATMENT29/10/22 (8:00 AM)1. RT FEEDS WITH 100 ML MILK + 200 ML FREE WATER 2ND HOURLY2. TAB. PENTOXYPHYLLINE 400 MG/PO/BD3. TAB. LASIX 40 MG/PO/BD4. TAB. SPIRANOLACTONE 25 MG/PO/OD5. SYP. LACTULOSE 30 ML/PO H/S6. TAB. UDILIV 300 MG/PO/BD7. TAB. RIFAGUT 550 MG/PO/BD8. INJ. CEFOTAXIM 2GM/IV/BD29/10/22 (2:00 PM)1. STARTED ON IONOTROPESINJ. NORADRENALINE 2 AMP IN 46 ML NS @ 8 ML/HR INCREASE/DECREASE TO MAINTAIN MAP OF 65 MMHGLATER AROUND 4:00 PM BP HASN'T PICKED UP, EVEN AFTER MAXIMUM OF NORADRENALINETHEN VASOPRESSIN HAVE BEEN STARTED29/10/22 (6:00PM)1. PLAN FOR ELECTIVE INTUBATION IN V/O LOW GCS2. INJ. NORADRENALINE 2 AMPLES + 46 ML NS @ 24 ML/HR3. INJ. VASOPRESSINE 1 AMPOULE IN + 49 ML NS @ 2 ML/HR4. INJ. DOBUTAMINE 25 MCG (5M) + 45 ML NS @ 3.6 ML/HR5. INJ. SODIUM BICARBONATE 100 MEQ STAT IV6. INJ. 100 MEQ OF SODIUM BICARB IN 100 ML NS OVER 1 HOUR7. INJ. SODABICARBS 25 MEQ IN 50 ML NS OVER 30 MIN29/10/22 (9:00 PM)PATIENT WAS INTUBATED WITH ET 7.5 AFTER PASSING BUJIE POSITION WAS CONFIRMED WITH 5 POINT PROFILE AUSCULTATIONPRE OXYGENATION FOR 3 MINUTES DONEPRE INTUBATION MEDICATIONINJ. MIDAZ 3 CC IV GIVENINJ. ATRACURIUM 1CC IV GIVENINJ. ONDEN 4 CC IV GIVENPOST INTUBATION VITALSHR- 120 BPMBP- NOT RECORDABLECVS- S1, S2 +R/S- B/L AIR ENTRY PRESENTRIGHT INFRA AXILLARY CREPTS +AFTER 20 MINUTES OF INTUBATIONTHERE WAS A SUDDEN FALL OF HEART RATEHR- 42 BPMSPO2- 34%PATIENT WAS ARRESTED IN VIEW OF WHICH CPR WAS INITIATED29/10/22 (9:55 PM)DUE TO SUDDEN FALL IN HEART RATE AND SATURATION SPO2 35 MM OF HG AND SUDDEN CARIDAC ARREST, CPR WAS INITIATED ACCORDING TO AHA GUIDE LINESBP NOT RECORDABLE, PULSE NOT RECORDABLE, INJ. ADRENALINE 1CC IV GIVEN, CPR INITIATED29/10/22 (10:00 PM)BP &PR NOT RECORDABLEINJ. ADRENALINE 1 CC/IV GIVEN CPR CONTINUED29/10/22 (10:05 PM)BP &PR NOT RECORDABLEINJ. ADRENALINE 1 CC/IV GIVEN CPR CONTINUED29/10/22 (10:10 PM)BP &PR NOT RECORDABLEINJ. ADRENALINE 1 CC/IV GIVEN CPR CONTINUED29/10/22 (10:15 PM)BP &PR NOT RECORDABLEINJ. ADRENALINE 1 CC

IV GIVEN CPR CONTINUED29/10/22 (10:20 PM)BP &PR NOT RECORDABLEINJ. ADRENALINE 1 CC/IV GIVEN CPR CONTINUED29/10/22 (10:25 PM)BP &PR NOT RECORDABLEDESPITE OF CONTINUOUS RESUSCITATIVE EFFORTS PATIENT COULD NOT BE REVIVED AND DECLARED DEATH AT 10:25 PM ON 29/10/22

Patient outcome:.

DIED DURING PRESENT ADMISSION.

Case 22:

70/M

Diagnosis ALTERED SENSORIUM (RESOLVED)SECONDARY TO SEPSIS- SEPTIC ENCEPHALOPATHY WET GANGRENE OF LEFT 3RD TOE- S/P DISARTICULATION OF 3 RD TOE ON 10-08-2023 WITH CELLULITIS OF LEFT LEG WITH UNCINTROLLED SUGARS WITH THYOE II DM AND HTN WITH ANAEMIA (NCNC) Case History and Clinical Findings C/O ALTERED SENSORIUM SINCE 3 DAYS C/O ULCER OVER LEFT FOOT SINCE 3 MONTHS C/O BURNING MICTURITION SINCE 15 DAYS HOPI :PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH AGO AND HE HAD ULCER OVER THE LEFT FOOT-3RD TOE NO H/O TRAUMA,INJURY BURNING MICTURITION SINCE 15 DAYS,ALTERED SENSORIUM SINCE 3 DAYS H/O IRRELAVANT TALK,NOT ABLE TO RECOGNISE ATTENDERS9ALTERED SENSORIUM MORE DURING EVENING) N/H/O FEVER,VOMITING,LOOSE STOOLS,PAIN ABDOMEN,GIDDINESS PAST HISTORY:K/C/O TYPE 2 DMSINCE 25YRS ON INJ HUMAN MIXTARD 10-100 SINCE 20 YRS K/C/O HTN SINCE 20 YRS ON TAB TELMA-H PO/OD

PERSONAL HISTORY : SLEEP-ADEQUATE DIET-MIXED APETITE-NORMAL ADDICTIONS-OCCASIONAL ALCOHOL CONSUMPTION ,H/O SMOKING ,STOPPED 1 YR BACK ALLERGIES-NONE O/E PATIENT IS CONSCIOUS, IRRITABLE, ORIENTED TO TIME, PLKACE, PERSON NO SIGNS OF PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDAL EDEMA VITALS : TEMP-96.8 F BP-120/70 MMHG PR-78 BPM GRBS-171 MG/DL SPO2-97 ON RA CVS :S1,S2 HEARD,NO MURMURS RS:BAE +,NVBS CNS: GCS RIGHT LEFT POWER UL 5/5 5/5 LL 5/5 5/5 TONE UL N N LL N N REFLEXES B 2+ 2+ T 1+ 1+ S - K 1+ 1+ A - PLANT FDLEX FLEX P/A :SOFT,NON TENDER ,BOWEL SOUNDS+

Investigation HB -8.8 MG/DL TLC-18000 /CUMM PCV:25.8 VOL% PLT COUNT-3.88 LAKH/CUMM RBC-3.27MILLION/CUMM APTT:31SEC INR:1.11 UREA-23 MG/DL S.CREAT-1.7 MG/DL NA-132 MEQ/L K-3.8 MEQ/L CA:9.7MG/DL CL-99 MEQ/L TB/DB-0.59/0.20 SGOT/SGPT-14/16 ALP-286IU/L TP-5.8GM/DL A/G-0.99GM/DL RBS:60MG/DL FBS:222MG/DL HBA1C:7.4 2D ECHO : NO RWMA, MILD AR +, / MIULD TR +/ ASOCIATED WITH PAH , EF-67%, GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION + IVC - 1.10 CMS, COLLAPSING COLOR DOPPLER OF LEFT LL : ALL EXAMINED ARTERIES SHOW NORMAL TRIPHASIC WAVE FRONT EXCEPT ATA, PTA, PERONEAL , DPA ARTERIES WHICH SHOW BIPHASIC WAVEFORM AND HIGH VELOCITIES ATHEROSCLEROTIC CHANGES IN ALL EXAMINED ARTERIES SCUBCUTANOOUS EDEMA IN LEFT LOWER LIMB

LEFT INGUINAL LYMPHADENOPATHY NO EVIDENCE OF DVT Treatment Given(Enter only Generic Name) IV FLUIDS AT 75ML/HR INJ PIPTAZ 3.375GM IV QID FOR 3 DAYS INJ CLINDAMYCIN 600MG IV BD FOR 3 DAYS TAB TELMA-H PO/OD INJ. OPTINEURON 1 AMP IV /OD Advice at Discharge REFER TO HIGHER CENTRE PATIENT AND PATIENT ATTENDER HAVE BEEN EXPLAINED ABOUT THE CONDITION OF THE PATIENT THAT IS ALTERED SENSORIUM SECONDARY TO SEPTIC ENCEPHALOPATHY WITH LEFT 3RD TOE GANGRENE WITH CELLULITIS OF LEFT LEG WITH TYPE2DM HTN.THE SURGERY TEAM HAS ADVICED FOR VASCULAR SURGEON OPINION , THE CASE IS REFERED TO HIGHER CENTRE FOR VASCULAR SURGEON INTERVENTION AND MANAGEMENT. THEN HOSPITAL MANAGEMENT, STAF, DOCTORS ARE NOT RESPONSIBLE FOR ANY UNTOWARD EFECT WHILE TRANSPORTING THE PATIENT AND OUTSIDE THE HOSPITAL .

Patient outcome:

Died after taking home

Case 23:

36,M

UNCONTROLLED SUGAR SECONDARY TO SEPSIS SEPTIC ENCEPHALOPATHY (RESOLVED) WET GANGRENE OF RIGHT GREAT TOE(RAYS AMPUTATION DONE) ACUTE RENAL FAILURE ON CHRONIC KIDNEY DISEASE(DIABETIC NEPHROPATHY SINCE 2 YRS) ANEMIA OF SHRONIC KIDNEY DISEASE THROMBOCYTOPENIA (RESOLVED) H/O DIABETES MELLITUS SINCE 10YRS H/O HYPERTENSION SINCE 2YRS Case History and Clinical Findings A 35 YR OLD MALE WHO WAS ATRUCK DRIVER BY OCCUPATION WAS BROUGHT TO THE CASUALITY WITH C/O ALTERED SENSORIUM AND GENERALISED WEAKNESS SINCE 1WEEK HOPI.

PT. WAS APPARENTLY ASYMPTOMATIC 10YRS AGO THEN HE DEVELOPED COUGH AND GENERALISED WEAKNESS FOR WHICH HE WENT TO HOSPITAL AND DIAGNOSED WITH DM AND WAS PRESCRIBED OHAS SINCE THEN HE STARTED USING OHAS BUT WAS ON IRREGULAR MEDICATION AND HAD POOR CONTROL OF SUGARS .THEN WAS ON INSULIN SINCE 7YS,STOPPED USING INSULIN FROM 15DAYS 2 YRS BACK HE DEVELOPED BOTH LL SWELLING WHICH GRADUALLY PROGRESSED TO ANASARCA SINCE THEN HE HAD FREQUENT ATTACKS OF HYPOGLYCEMIA AND DECREASED URINE OUTPUT 3 MONTHS BACK.PT.DEVELOPED FEVER WITH ULCER OVER RIGHT GREAT TOE. LOWER LIMB AND FACIAL PUFFINESS AGGRAVATED ,BROUGHT TO OUR HOSPITAL AND WAS ADMITTED AND DISCHARGED SINCE 7DAYS,PT. HAD GENERALISED WEAKNESS , ALTERED BEHAVIOUR ,INCREASED SLEEPINESS DURING DAY TIME,ALTERED SLEEP CYCLE SINCE 1WEEK, AND WAS BROUGHT TO OUR HOSPITAL PAST HISTORYK/C/O DM SINCE 10YRS AND ON INSULIN DIAGNOSED WITH DM 10YRS BACK AND WAS PRESCRIBED OHAS SINCE THEN HE STARTED USING OHAS BUT WAS ON IRREGULAR MEDICATION AND HAD POOR CONTROL OF SUGARS .THEN WAS ON INSULIN SINCE 7YS.STOPPED USING FROM 15DAYS K/C/O HTN SINCE 2YRS AND ON REGULAR MEDICATION NOT A K/C/O TB/CAD/EPILEPSY/ASTHMA PERSONAL HISTORYMIXED DIET APPETITE DECREASED BOWEL AND BLADDER HABITS -REGULAR ADDICTIONS-CHRONIC ALCOHOLIC AND TAKES DAILY 90-180ML FOR ABOUT 10YRS AND STOPPED 2 YRS BACK NO ALLERGIES GENERAL EXAMINATION: AT PRESENTATION PT. IS DROWSY/COHERENT/COOPERATIVE PALLOR PRESENT B/L PEDAL EDEMA PRESENT NO ICTERUS, CYNOSIS, CLUBBING, LYMPHEDENOPATHYTEMP- 98FPR-98BPMBP150/100MMHGSPO2-98% @ RAGRBS-HIGH CVS- S1S2+,NO MURMURSRS- BAE+,NVBS HEARDP/A- SOFT,NON TENDER,BOWEL SOUNDS+CNS- ORIENTED TO TIME,PLACE AND PERSON

LEVEL OF CONSCIOUSNESS- DROWSY/AROUSABLE SPEECH-SLURRED NO SIGNS OF MENINGEAL IRRITATION CRANIAL NERVES INTACT NO SENSORY ABNORMALITY DETECTED GCS 15/15 B/L PUPILS NORMAL IN SIZE AND REACTIVE TO LIGHT AT THE TIME OF DISCHARGE: PT. IS CONSCIOUS/COHERENT/COOPERATIVE COURSE IN THE HOSPITAL: 35 YEAR OLD MALE ADMITTED IN THE HOSPITAL WITH ABOVE MENTIONED COMPLAINTSNECESSARY INVESTIGATIONS WERE DONE , CONSERVATIVELY MANAGED 3 UNITS PRBC TRANSFUSIONS DONE ON[18/2/23,19/2/23,21/2/23]SYMPTOMS SUBSIDEDPATIENT HEMODYNAMICALLY STABLE AND PLANNED FOR DISCHARGE GENERAL SURGERY OPINION TAKEN I/V/O DIABETIC FOOT ADVICED ARTERIOVENOUS DOPPLER OF RT. LOWER LIMB,C/S OF DIABETIC FOOT SWAB ARTERIOVENOUS DOPPLER OF RIGHT LOWER LIMB: 1.PROXIMAL PTA AND DPA SHOW BIPHASIC WAVIFORM,REST OF ARTERIES SHOW TRIPHASIC WAVIFORM 2.ALL EXAMINED VEINS SHOW NORMAL COLOUR UPTAKE WAVIFORM,RESPIRATORY PHASICITY DIABETIC FOOT ULCER SWAB C/S: FEW EPITHELIAL CELLS,FEW DISINTEGRATED PUS CELLS,MODERATE NUMBER OF GRAM NEGATIVE BACILLI,PLENTY OF GRAM POSITIVE BUDDING YEAST CELLS SEEN. KLEBSIELLA PNEUMONIA ISOLATED SENSITIVE TO GENTAMICIN,COTRIMOXAZOLE,AMIKACIN,MEROPENEM RESISTANT TO AMOYCLAV,CEFUROXIME,CEFTAZIDIME,CEFEPIME OPHTHALMOLOGY OPINION TAKEN I/V/O ANY DM AND HTN RETINOPATHIC CHANGES ADVICE : FUNDOSCOPY DONE -NO RAISED ICT ,NO CHANGES OF HTN AND DIABETIC RETINOPATHY CHANGES NEPHROLOGY OPONION TAKEN I/V/O SR.UREA-108MG/DL AND S.CREA-3.1MG/DL ADVICED TAB.TELMA 40MG PO/OD INJ.LASIX 20MG IV/BD INJ.MEROPENEM 1GM IV/TID

INJ.INSILIN ACCORDINGLY EVERY 4TH HRLY ENDOCRINOLOGY OPINION TAKEN I/V/O Investigation PT-15SECS APTT-31SECS INR-1.11 ECG-NORMAL SINUS PATTERN 2D ECHOMILD TO MODERATE TR+ WITH PAH, MILD MR+,TRIVIAL AR+ NO RWMA,NO AS/MS,CONCENTRIC LVH+ GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DISFUNCTION EF-56% BGT-A POSITIVE HEMOGRAM; HB. , TLC PLC GM/DL CELLS/CUMM 17/02/23 6.0 21,600 95,000 19/02/23 5.8 15,400 42,000 20/02/23 6.5 13,500 46,000 21/02/23 6.3 11,000 33,000 22/02/23 8.2 14,000 96,000 23/2/23 7.1 9000 1,OO,200 USG ABDOMEN: MODERATE ASCITIS LEFT MILD PLEURAL EFFUSION C/S OF URINE: NO GROWTH SEEN C/S OF BLOOD: SKIN COMMENSALS GROWN 24 HRS URINARY PROTEIN -654MG/DAY 24HRS URINARY CREATININE -2.89G/DAY

Treatment Given(Enter only Generic Name) NBM TILL FURTHER ORDERSIVF -NS@ 50ML /HRINJ.NAHCO3NBM TILL FURTHER ORDERSIVF -NS@ 50ML IV STATINJ.NAHCO3 50MEQ/L F/B 50MEQ/LINJ. HAI 6U IV STAT F/B ACCODING TO GRBS INJ.PIPTAZ 4.5G IV STAT F/B 2.25GIV TID INJ.CLINDAMYCIN 600MG IV / TIDSTRICT I/O CHARTINGGRBS MONITORING HOURlY 21/2/23: DATE TIME GRBS INSULIN GIVEN 21/02/23 8AM 101 4U HAI+4U NPH 2PM 127 6U HAI 8PM 176 8U HAI 22/02/23 8AM 201 6U HAI+4 U NPH 2PM 100 6U HAI 8PM 79 4U HAI 23/02/23 8AM 198 6U HAI+4U NPH 12PM 100 6U HAI 8PM 92 4U HAI Advice at Discharge STRICT DIABETIC DIET INJ.MIXTARD /SC 12U -----0-----8U INJ.ERYTHROPOITIN 400UNITS/SC/TWICE WEEKLY TAB.LASIX 40MG PO/BD TAB.NICARDIA 10MG PO/TID TAB.BACTRAM DS PO/BD X 5DAYS TAB.CHYMEROL FORTE PO/TID TAB.NODOSIS 500MG PO/OD TAB.SERAX FORTE 20MG PO/TID FLUID RESTRICTION <1.5 LITS/DAY SALT RESTRICTION <2GM/DAY RIGHT LOWE LIMB ELEVATION REGULAR DRESSINGS ACTIVE AMBULATION

Patient outcome:. patient is in good recovery

Case 24:

56/M

Diagnosis ALTERED SENSORIUM SECONDARY TO DENGUE VASCULITIS RIGHT UMN FACIAL PALSY; HYPERKALEMIA(RESOLVED); NON OLIGURIC AKI(RESOLVED); MILD ANEMIA; CAD - TO LAD,LCX (6 YEARS AGO); DENOVO TYPE II DM. Case History and Clinical Findings PRESENTING COMPLAINTS: Fever since 12 days. Burning micturition since 12 days. HOPI:

65 year male, apparently asymptomatic 12 days back then he had gradual onset of fever since 12 days initially high grade fever associated with chills, history of burning micturition on day 3 of illness. Patient sought for consultation at local Rmp and treated with oral medication. On day 4 of illness, the patient was brought to another local hospital for further management, there he was treated with iv Fluids for 3days. As fever didn't subside, patient was shifted to another hospital; there he was treated with IV antibiotics and 1 unit of platelet transfusion was done in view of low platelet count. During the transfusion of platelet patient had chills. From next day of transfusion patient developed slurred speech and was reffered to our hospital in view of hemodialysis. Now admitted for further evaluation and management. Past history:History of CAD 6yrs agoHistroy of platelet transfusion on 24/10/22 Not k/c/o DM ,HTN, Asthma,Epilepsy. Personal history: Diet : mixed Appetite decreased Bowel and bladder movements - constipation since 3 days Consumes alcohol 180ml once in 2 weeks stopped since 6yrs Smokes bedi 7 per day since age of 20 yrs Family history insignificant General physical examination: Patient conscious, Oriented to time ,and persons but not to place on day of admission No pallor ,icterus,cyanosis, clubbing, lymphadenopathy , oedema of feet VITALS: Temp :99°f Pulse rate:86 bpm Resp.rate- 16cpm Bp- 130/80mmhg Spo2-95%RA GRBS:253mg/dl SYSTEMIC EXAMINATION CVS: S1, S2 +, no thrills and murmurs PER ABDOMEN- soft,non tender, bowel sounds+ , umbilicus central inverted , no scars and sinuses. RS: BAE+,NVBS, no added sounds heard CNS

HMF:

Patient is not oriented to time,place and person at the time of admission.

pupil- B/L normal size reacting to light.Speech- improvedDeviation of mouth to rightTongue fasiculations present Cranial nerve :7th - Deviation of mouth to rightTongue fasiculations , wrinking right> left MOTOR : POWER:- Upperlimb LowerlimbRight - 5/5 5/5Left - 5/5 5/5TONE:- upperlimb LowerlimbRight Hypertonia >HypertoniaLeft - Hypertonia >HypertoniaTone of right limbs greater than leftREFLEXES:Biceps +2 of both limbsTriceps +1 of both limbsSupinator +1 of both limbsKnee +2 of both limbsAnkle -right limb mute &leftlimb +1Plantar - flexion both limbsSENSORY :BILATERAL: TOUCH , PAIN ,TEMP +Cerebellar signs are absent.Gait - short stepping gaitNIHSS_ 13 points, moderate CNS EXAMINATION AT THE DISCHARGE: CNS

HMF intact.pupil- B/L normal size reacting to light.Speech- improvedDeviation of mouth to rightTongue fasiculations present Cranial nerve :7th - Deviation of mouth to rightTongue fasiculations , wrinking right> left MOTOR : POWER:- Upperlimb LowerlimbRight - 5/5 5/5Left - 5/5 5/5TONE:- upperlimb LowerlimbRight Hypertonia >HypertoniaLeft - Hypertonia >HypertoniaTone of right limbs greater than leftREFLEXES:Biceps +2 of both limbsTriceps +1 of both limbsSupinator +1 of both limbsKnee +2 of both limbsAnkle -right limb mute &leftlimb +1Plantar - flexion both limbsSENSORY :BILATERAL: TOUCH , PAIN ,TEMP +Cerebellar signs are absent.Gait - short stepping gaitNIHSS_ 13 points, moderate

Neck stiffness present..

COURSE IN THE HOSPITAL:

A 65 year male clinically presenyed to the casuality with above mentioned complaints. Upon admission initial neurological examination showed right sided weakness and same side facial palsy. MRI BRAIN stroke protocol was done which showed Acute Left Frontal lobe infract. Necessary investigations were done. Patient was shifted to AMC and haded over to the ICU team. Hemogram on admission was Hb ; TLC cells/mm3; platelet count lakhs/mm3. The patient waas found to be having high post lunch blood sugars and HbA1c 7.2; for which he was started on insulin and his blood sugars were monitored. During the stay in hospital he was treatred with oral anti platelet, antipyretic and other supportive medications. Physiotherapy was advised and done. At the time of discharge his hemogram wasHb ; TLC cells/mm3; platelet count lakhs/mm3. His condition was gradually improved and was discharged in a hemodynamically stable condition. Investigation 2D ECHO: (DONE ON 26/10/22) RWMA+ ,( LAD &LCX HYPOKINESIA) MODERATE TR WITH PAH(55MMHG) MILD MR; TRIVIAL AR SCLEROTIC AV, NOAS/MS EF-43% MODERATE LV DYSFUNCTION DIASTOLIC DYSFUNCTION, NO PE IVC SIZE- NORMAL ON 27/10/22: RWMA+ ,( LAD &LCX HYPOKINESIA) MODERATE TR WITH PAH(55MMHG) MILD MR; TRIVIAL AR SCLEROTIC AV, NOAS/MS EF-43% MODERATE LV DYSFUNCTION DIASTOLIC DYSFUNCTION, NO PE IVC SIZE- NORMAL DILATED- LV MILD DILATED - LA USG (ON 26/10/22) B/L GRADE 1 RPD CHANGES WITH B/L RENAL CORTICAL CYSTS Treatment Given(Enter only Generic Name) Page-4 1) INJ. ZOFER 4MG/BD

2) INJ. NEOMOL 1GM/IV/ SOS IF TEMP @>101°F 3) TAB ECOSPRIN 75MG/PO/OD@ 2PM 4) TAB ATROVAS 40 MG /PO/HS 5) TAB DOLO 650MG /PO/BD 6)TAB PAN 40MG PO/OD 7) VITALS , GRBS ,I/O 8) T.METFORMIN 500MG/PO/0D 9) SURUP ARISTOZYME 15ML/PO/TID 10) PHYSIOTHERAPY Advice at Discharge 1) TAB ECOSPRIN 75MG/PO/OD@ 2PM 2) TAB ATROVAS 40 MG /PO/HS 3) T.METFORMIN 500MG/PO/0D 4) HOME MONITORING OF BLOOD SUGARS

Patient outcome:. Improved at the time of admission,Good recovery..

Case 25:

46/M

Diagnosis ALTERED SENSORIUM- HYPOACTIVE DELIRIUM ? SECONDARY TO DYSELECTROLYTEMIA CKD (DIABETIC NEPHROPATHY) K/C/O DM2 DENOVO HTN Case History and Clinical Findings 54 year male came to casualty on 27-10-22 with complaints of hiccups since 5 days and altered sensorium since morning HOPI: Pt was apparently asymptomatic 5 days back then he had continuous hiccups since 5 days Altered sensorium since morning (He had ? up rolling of eyeballs and frothing 1 episode in the morning not associated with any involuntary movements or involuntary micturition or tongue bite) No h/o fever,headache,giddiness,vomiting No other complaints Past history: He had similar episode 6 months back &2 months back

2 months back he was admitted in hospital with similar complaints and was found out to have dyselectrolytemia - treated symptomatically K/c/o DM since 7 years ( he had trauma 5 years back to foot which was not healing properly so he went to the hospital and was diagnosed as diabetic) Initially he took medication but his sugars were not under control Then he was switched to insulin under doctor’s advice 20U in the morning and 15 units in the night since 3 months N/k/c/o HTN, asthma , epilepsy, cad, cvd H/o trauma to head ( Rta -bike skid) 1 month back he had aLaceration Personal history : Diet : mixed Appetite: normal Bowel and bladder habits: regular Addictions: none Sleep : adequate Family history: Insignificant General examination: Pt is conscious coherent and cooperative Delayed response Moderately built and nourished Pallor , icterus, cyanosis, clubbing , lymphadenopathy, edema are absent Vitals: Temp; 98 BP: 140/80 PR: 82 bpm RR:20/min Systemic examination: CNS; Higher functions:

Right handed Conscious Delayed response Oriented to time place and person Memory: recent- present Immediate: present Remote: present Speech: slurred Cranial nerve examination: normal Spinomotor system: Right Left BULK: U/L- Normal Normal L/L- Normal Normal TONE: U/L Normal normal L/L Normal normal Right Left POWER: U/L- hand 4/5 4/5 - elbow 4/5 4/5 - shoulder 4/5 4/5 L/L- hip 4/5 4/5 - knee 4/5 4/5- ankle 4/5 4/5 Right Left REFLEXES: Biceps - Triceps - Supinator - Knee + + Ankle -

Plantar Flexion Flexion 4c) Sensory system examination: As patient is drowsy examination of sensory system is limited Right Leftcrude touch present presentfinetouch - - pain Present presentTemperature Present PresentVibration Couldn’t be elicited stereognosis- Present present2 pt discrimination- - Proprioception Couldn’t be elicited Graphesthesia Absent Absent Cerebellar system : Finger nose test : unable to do Knee heel test: unable to do Finger finger: unable to do Nystagmus: no Gait: ataxic gait CVS: s1 s2 heard No murmurs Respiratory system; normal vesicular breath sounds are heard Abdomen: soft non tender no organomegly COURSE IN HOSPITAL: A 54/M WAS BROUGHT TO CASUALTY ON 27-10-22 WITH C/O HICCUPS SINCE 5 DAYS AND ALTERED SENSORIUM SINCE MORNING WITH STABLE VITALS AND NECESSARY INVESTIGATIONS WERE DONE AND WITH A DIAGNOSIS OF HYPOACTIVE DELIRIUM ? SECONDARY TO DYSELECTROLYTEMIA PATIENT WAS MANAGED SYMPTOMATICALLY. PATIENT IMPROVED OVER TIME AND WAS DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION WITH FOLLOWING ADVICE Investigation HEMOGRAM: ON 27-10-22: HB:12.2GM/DL, TLC:13400/CUMM, PLT:3.76LAKHS/CUMM ON 29-10-22: HB:10.1GM/DL, TLC:10,500/CUMM, PLT:3.3LAKHS/CUMM ON 30-10-22 HB:10.8GM/DL, TLC:12,500/CUMM, PLT:2.95LAKHS/CUMM ON 31-10-22 HB:10.8GM/DL, TLC:12,600/CUMM, PLT:3.13LAKHS/CUMM ON 2-11-22 HB:10.7GM/DL, TLC:10,700/CUMM, PLT:2.79LAKHS/CUMM SERUM ELECTROLYTES: ON 27-10-22: MAGNESIUM:1.8MG/DL ON 28-10-22: SODIUM:130, POTASSIUM:2.6, CHLORIDE:92

ON 29-10-22: SODIUM:133, POTASSIUM:3, CHLORIDE:95 ON URINARY ELECTROLYTES: ON 27-10-22: CHLORIDE:207MMOL/L, POTASSIUM:10.7, SODIUM:188 ON 29-10-22 CALCIUM:6.50N 31-10-22 24HRS CALCIUM:104MG/DAY USG ABDOMEN: RAISED ECHOGENECITY OF B/L KIDNEYS USG CHEST: MINIMAL RIGHT PLUERAL EFFUSION MRI BRAIN: OLD LACUNAR INFARCT IN LEFT STRIATO-CAPSULAR REGION INCIDENTALLY DETECTED - PROMINENT CISTERNA MAGNA 2D ECHO: GOOD LV SYSTOLIC FUNCTION NO MR/AR/TR DIASTOLIC DYSFUNCTION + EF:58% Treatment Given(Enter only Generic Name) 1) IV fluids NS @ UO + 30ml/hr 2) Inj pan 40mg IV OD 3) Inj.optineuron 1 amp in 100 ml NS IV/OD 4) Syp potchlor 15ml in 1 glass of water PO/TID 5) Inj.kcl 3 amp (60 meq) + 1 amp MGSO4 (2gm) in 500 ml NS @ 100 ml/hr 6) Inj.H.Mixtard Insulin SC BD 20u (8am) -- x -- 15u (8pm) before meal 7) Tab Cinod 10 mg PO/OD 8) Strict diabetic diet COURSE IN HOSPITAL:

A 54/M WAS BROUGHT TO CASUALTY ON 27-10-22 WITH C/O HICCUPS SINCE 5 DAYS AND ALTERED SENSORIUM SINCE MORNING WITH STABLE VITALS AND NECESSARY INVESTIGATIONS WERE DONE AND WITH A DIAGNOSIS OF HYPOACTIVE DELIRIUM ? SECONDARY TO DYSELECTROLYTEMIA PATIENT WAS MANAGED SYMPTOMATICALLY. PATIENT IMPROVED OVER TIME AND WAS DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION WITH FOLLOWING ADVICE Advice at Discharge 1) Tab Pan 40mg PO/OD 2) Tab Zincovit PO/OD 3) Syp Potchlor 10ml in 1 glass of water PO/BD FOR 4 DAYS 4) Inj.H.Mixtard Insulin SC/BD 20u (8am) -- x -- 15u (8pm) before meal 5) Tab Cinod 10 mg PO/OD 6) Strict diabetic diet &regular exercise

Patient outcome: Good recovery

Case 26:

31/M

Diagnosis WERNICKES ENCEPHALOPATHY

?ALCOHOL WITHDRAWL DELIRIUM ?ALCOHOL WITHDRAWL PSYCHOSIS ALCOHOL DEPENDENCE SYNDROME TOBACCO DEPENDENCE SYNDROME Case History and Clinical Findings

A 30 year old male patient resident of Gudipally came to the casualty on 23/11/22 of altered behaviour since yesterday Involuntary micturition since yesterdayGiddiness since morningHOPI.Patient was apparently asymptomatic till 12 am last night then he started behaving abnormally which was sudden in onset in terms of not .responding when spoken to,irrelevant talk which is repetitive and self talking.patient is irritable every few minutes and abuses family members at times.Patient had history of alcohol consumption since 10 years currently 6 to 10 units daily throughout day,reports craving for alcohol, sweating and trembling when he doesn't consume alcohol.patient stopped consumption for the past 10 days till yesterday but was given 3 units I/v/o tremors@ 10:30 am which subsided after consumption . patient.also reported double images and slurring of speech and memory disturbances since 10 days.patient reports consumption of tobacco in the form of smoking(10 cigarettes per day).PAST HISTORYH/O fall 1 month back ,sustained injury @ head.N/K/C/O DM,HTN, TB ASTHAMA, EPILEPSY.FAMILY HISTORY: not significantPERSONAL HISTORYDIET: MixedAPPETITE: decreasedSLEEP: disturbedBOWEL AND BLADDER MOVEMENTS: regularADDICTIONS: alcoholic since 10 years.ON EXAMINATION.Patient is conscious.No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy,edema.TemperatureBP: 120/80 mm hgPR:68/minRR:18/ minSPO2:98% at room air.GRBS: 98MG/DL.SYATEMIC EXAMINATIONCNS.HMF: orientation to place and person present and to time absent.PUPILS: NSRLSPEECH: normal.CRANIAL NERVE EXAMINATION: INTACTSENSORY SYSTEM NORMALMOTOR SYSTEM RIGHT. .LEFTTONE. UL Normal normal LL. Normal. normalPOWER. UL. 4/5. 4/5 LL. 4/5. 4/5.REFLEXES. RIGHT. LEFTBICEPS. 2+. 2+TRICEPS. 2+. 2+SUPINATOR. 2+. 2+KNEE. 2+. 2+ANKLE. 2+. 2+PLANTAR. 2 +. 2+SENSORY SYSTEM: normal.CEREBELLAR SIGNSFINGER NOSE TEST - IN COORDINATION PRESENTFINGER FINGER TEST- IN COORDINATION PRESENTROMBERGS NEGATIVEDYSDIADOKINESIA- NEGATIVEGAIT - NORMALCVS examination:S1, S2 are heard.No murmurs.Respiratory system examination:Inspection: Chest is moving bilaterally symmetrical. No pulsations.Palpation: Trachea is central in postion.Percussion: ResonantAuscultation: Breath sounds are vescicular.Abdomen examination:Inspection: Shape is scaphoid. Movements are equal.Palpation: No tenderness Normal temperature No organomegaly.Percussion: Normal.Auscultation: Bowel sounds heard.COURSE IN THE HOSPITAL:30 YEAR OLD MALE WITH ABOVE MENTIONED COMPLAINTS GOT ADMITTED AND NECESSARY INVESTIGATIONS WERE SEND AFTER INITIAL ASSESSMENT.ON EXAMINATIONHMF: orientation to place and person present and to time absent.PUPILS: NSRLSPEECH: normal.CRANIAL NERVE EXAMINATION: INTACTSENSORY SYSTEM NORMALMOTOR SYSTEM RIGHT. .LEFTTONE. UL Normal normal LL. Normal. normalPOWER. UL. 4/5. 4/5 LL. 4/5. 4/5.REFLEXES. RIGHT. LEFTBICEPS. 2+. 2+TRICEPS. 2+. 2+SUPINATOR. 2+. 2+KNEE. 2+. 2+ANKLE. 2+. 2+PLANTAR. 2 +. 2+SENSORY SYSTEM: normal.CEREBELLAR SIGNSFINGER NOSE TEST - IN COORDINATION PRESENTFINGER FINGER TEST- IN COORDINATION PRESENTROMBERGS - NEGATIVEDYSDIADOKINESIANEGATIVEGAIT - NORMALPSYCHAITRY OPINION WAS TAKEN IN VIEW OF ABOVE MENTIONED COMPLAINTS AND WAS STARTED ON TAB LORAZEPAM FOR 5 DAYS,TAB OLANZAPINE 2.5 MG FROM DAY 2,TAB LIBRIUM 10 MG AND 25 MG FROM DAY 3.ENT REFERRAL WAS TAKEN IN VIEW OF THROAT PAIN AND WAS DIAGNOSED AS GERD AND WAS PUT ON SYMPTOMATIC TREATMENTOPTHALMOLOGY OPINION WAS TAKEN IN VIEW OF BLURRED VISION AND ADVISED FOR SPECTACLE USAGE.PATIENT CONDITION HAS BEEN GRADUALLY IMPROVED AND HENCE BEING DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION. Investigation MRI BRAIN PLAIN: SUBTLE FLAIR HYPER INTENSE SIGNAL SEEN IN POSTERIOR PERIVENTRICULAR WHITE MATTER USG ABDOMEN: GRADE 1 FATTY LIVER NO ORGANO MEGALY NO FEATURES SUGGESTIVE OF SEROSITIS Treatment Given(Enter only Generic Name) 1.IVF( NS,RL @ 75 ML/ HR2. INJ THIAMINE 200 MG IV/ TID3. INJ PAN 40 MG IV /OD/ BBF4.TAB LORAZEPAM 2 MG PO/BD[23/11/22-26/11/22]5. INJ LORAZ 2 MG/ IM/ SOS6.TAB OLANZAPINE 2.5 MG MD[25/11/22-29/11/22]7.TAB LIBRIUM 10 MG PO/TID[26/11/22-29/11/22]8.TAB LIBRIUM 25 MG PO/HS[26/11/22-29/11/22] Advice at Discharge 1.T.LIBRIUM 10 MG 1.....1.....2 - 2 DAYS

1....X....2- 2 DAYS X......X.....2- 2 DAYS X........X......1 - 5 DAYS 2.TAB OLANZAPINE 2.5 MG 1........X.......1 [15 TABLETS FOR 1 WEEK] 3.TAB MEMANTINE 5 MG 1.......X.......X[10 TABLETS FOR 1 WEEK] 4.NICOTEX GUMS 2 MG 1........1........X- 7 DAYS 5. TAB BENFOMET PLUS PO/OD - 2 WEEKS 6.2% BETADINE THROAT GARGLES DILUTED IN A GLASS OF WATER 3-4 TIMES/DAY- 1 WEEK 7.TAB PANTOP -D PO/OD [30 MINS BEFORE BREAKFAST ]- 1 WEEK 8.SPECTACLE USAGE DAILY.

Patient Outcome:

Good recovery

Case 27:

52,M

Diagnosis ? NEUROTOXOPLASMOSIS. ? NEUROTUBERCULOSIS. Case History and Clinical Findings PRIMARY SURVEY: PR:108 BPM BP:130/90 MM/HG RR:22CPM TEMP: 103F. SPO2:98% AT RA GRBS:113MG/DL CHEIF COMPLAINTS: Patient has complaints of generalised weaknesss since 1 week. h/o loss of speech and deviation of mouth since 3 days HOPI: PATIENT WAS BROUGHT TO CASUALITY WITH COMPLAINTS OF GENERALIZED WEAKNESS OF BOTH UPPER AND LOWER LIMBS SINCE 1 WEEK, COMPLAINTS OF UNABLE TO SPEAK SINCE 3 DAYS , COMPLAINTS OF DEVIATION OF MOUTH TO RIGHT SIDE SINCE 3 DAYS , COMPLAINTS OF FEVER SINCE 1 DAY. NO HISTORY OF SEIZURES,HEADACHE, GIDDINESS,SHORTNESS OF BREATH,FEVER,RASHES,PAIN ABDOMEN AND BURNING MICTURATION. SECONDARY SURVEY: GENERAL:PATIENT IS DROWSY, NON COHERENT , NOT ORIENTED TO TIME, PLACE AND PERSON.

HEAD: ATRAUMATIC, NORMOCEPHALIC ,GCS: E2V2M4[8/15] EYES: ATRAUMATIC, NO DISCHARGE, B/L PUPILS EQUAL REACTING TO LIGHT,RT EYE CATARACT. EARS:ATRAUMATIC, NO DISCHARGE. NOSE:ATRAUMATIC, NO DISCHARGE. NECK:NO NECK SWELLINGS,NO JVP DISTENSION,B/L CAROTIDS FELT, NO STRIDOR CHEST: B/L CHEST RISE EQUAL. HEART: S1S2 HEARD, NO MURMURS. LUNGS: BAE+ No added breath sounds. ABDOMEN: SOFT,NON TENDER,NO DISTENSION,BOWEL SOUNDS PRESENT PAST MEDICAL HISTORY: nil significant PAST SURGICAL HISTORY : no past surgical history NO SIGNIFICANT FAMILY HISTORY NO KNOWN DRUG OR FOOD ALLERGIES NO KNOWN COMORBIDITIES. Investigation MRI BRAIN PLAIN AND CONTRAST: Multiple ring enhancing lesions in pons mid brain bilateral straito capsular regions,left frontal lobe and right cerebellar hemisphere with extensive edema in the above areas. F/S/O Neurotoxoplasmosis/Neurotuberculosis DD-cryptococcal meningitis CSF ANALSYSIS: CSF CULTURE:zn stain-no acid fast bacilli seen. gram stain:few disintegrated pus cells,occasional gram positive cocci in pairs seen. CSF CYTOLOGY:few lymophocytes and few monocytes are seen. Treatment Given(Enter only Generic Name) 1)INJ NEOMOL 1GM IV/TID 2)INJ PANTAPRAZOLE 4OMG IV/STAT 3).INJ.ONDENSETRON 4MG IV/OD 4)OPTINEURON 4AMP IN 500ML NS IV/OD 5)TAB ECOSPORIN 75MG/RT/OD 6)TAB ROSUVASTATIN 40MG/RT/OD

7)INJ CLEXANE 60MG/SC/OD 8)INJ MANNITOL 100 /IV/TID 9)INJ LEVETIRACETAM 500MG /IV/BD 10)INJ THIAMINE 200MG /IV IN 500ML/NS/OD 11)TAB FOLIC ACID 5MG/RT/OD 1)TAB DOLUTGRAVIR 5OMG/OD+TAB LAMIVUDINE 300MG+TENOFOVIR 300MG 2)TAB SULFADIAZINE 1GM/RT/6TH HOURLY 3)TAB PYRIMETHAMINE 50MG/RT/6TH HOURLY 4)TAB LEUCOVORIN 15MG/RT/6TH HOURLY Advice at Discharge 1)TAB DOLUTEGRAVIR 5OMG/OD+TAB LAMIVUDINE 300MG+TENOFOVIR 300MG OD FOR 1 MONTH 2)TAB SULFADIAZINE 1GM/RT/6TH HOURLY FOR 1 MONTH 3)TAB PYRIMETHAMINE 50MG/RT/6TH HOURLY FOR 1 MONTH 4)TAB LEUCOVORIN 15MG/RT/6TH HOURLY FOR 1 MONTH 5]TAB.PANTAPRAZOLE 40MG RT/OD FOR 1 MONTH 6]TAB. MVT RT/OD

Patient outcome:

DIED at home

Case 28:

20/F

Diagnosis DIABETIC KETOACIDOSIS WITH DENOVO DIABETES MELLITUS WITH ACUTE GASTROENTRITIS (RESOLVED ) Case History and Clinical Findings PATIENT WAS BROUGHT TO CASUALTY WITH C/O FEVER SINCE YESTERDAY C/O ALTERED SENSORIUM SINCE TODAY MORNING HISTORY OF PRESENTING ILLNESS: PATIENT WAS APPARENTLY ASYMPTOMATIC TILL YESTERDAY THEN DEVELOPED FEVER,HIGH GRADE ASOCIATED WITH CHILLS AND RIGOR,NO DIURNAL VARIATION,RELIEVED WITH MEDICATION. ALTERED SENSORIUM SINCE TODAY MORNING NO C/O BURNING MICTURATION /VOMITINGS/LOOSE STOOLS/CHEST PAIN /PALPITATIONS/ORTHOPNEA/PND H/O POLYPHAGIA +,POLYDYPSIA + PAST HISTORY: N/K/C/O HYPERTENSION,DIABETES,THYROID DISORDERS,EPILEPSY,CVA,CAD PERSONAL HISTORY: DIET-MIXED APPETITE-NORMAL SLEEP-ADEQUATE

BOWEL AND BLADDER MOVEMENTS-REGULAR ADDICTIONS -NONE COURSE IN HOSPITAL 20 YEAR FEMALE WAS BROUGHT TO CASUALTY IN ALTERED SENSORIUM WITH GRBS 540MG/DL URINE FOR KETONE BODIES POSITIVE ABG DONE AND PRESENTED WITH DIABETIC KETOACIDOSIS WITH DENOVO DM .INSULIN INFUSION WAS STARED AND TAPPERED ACCORDING TO GRBS .PATIENT HAD COMPLAINTS OF WAXY EAR DISCHARGE ENT REFFERAL WAS TAKEN AND ADVICED FOLLOWED .PATIENT IS PLANNED FOR DISCHARGE AND HEMODYNAMICALLY STABLE STATE AND PLANNED FOR DISCHARGE. ENT REFFERAL WAS DONEAS SHE WAS HAVING COMPLAINTS OF RIGHT EAR PAIN AND RIGHT EAR DISCHARGE. EXMINATION WAS DONE AND MEDICATION WAS GIVENCIPLOX E/D 3D---3D---3D X5 DAYS OTRIVIN N/D 3D---3D---3D X 5 DAYS TAB. LEVOCET 5MG OD/HS X 5 DAYS GENERAL EXAMINATION: PATIENT IS CONCIOUS , COHERENT , COOPERATIVE , MODERATELY BUILT AND NOURISHED NO PALLOR , ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA VITALS: TEMPERATURE - AFEBRILE BP- 110/70 MM HG PR - 88 BPM GRBS-540MG/DL SYSTEMIC EXAMINATIONS: CVS - S1,S2 + NO MURMURS R/S - BAE+ NVBS+ P/A - SOFT, NON TENDER CNS- NFND Investigation HEMOGRAM:(30/9/23) 2/10/23 HB:- 11.1 GM/DL 10.9 TLC- 16700 CELLS/CUMM 6800

PLATLET COUNT-3.07 LAKHS/CUMM 2.32 SERUM CREATININE:0.8 MG/DL UREA:30 MG/DL SODIUM:136 MEQ/L POTASSIUM: 4.2 MEQ/L CHLORIDE:109 MEQ/L SERUM OSMOLALITY:287.8 RBS:308 CUE: SUGARS- ++ ALBUMIN-+ BILE SALTS AND PIGMENTS-NILL PUS CELLS-3-4 EPITHELIAL CELLS- 2-3 LFT: TOTAL BILIRUBIN: 5.33 MG/DL DIRECT BILIRUBIN :1.22 MG/DL AST :19 IU/L ALT: 10 IU/L ALKALINE PHOSPHATE:240 IU/L TOTAL PROTEIN:7.1 GM/DL A/G : 1.11 ABG: (30/9/23) (1/10/23) (2/10/23) (3/10/23) PH-7.13 7.32 7.42 7.44 PCO2-9.7 19.2 19.8 24.4 PO2-67.2 80.9 117 97.6 HCO3-3.1 9.7 12.8 16.6 ST.HCO3-7.3 13.6 16.9 19.9 BEB: - 26.1 -14.4 -9.5 -5.5 O2 SAT- 93.4 96.7 98.1 97.7 1/10/23 SERUM ELECTROLYTES: NA - 133 K-4.1

CL- 104 URINARY KETONE BODIES- + LDH-579 COOMBS TEST; -VE HBA1C-7.0 2/10/23 NA - 137 K-2.9 CL- 104 USG ABDOMEN - NO SONOLOGICAL ABNORMALITIES Treatment Given(Enter only Generic Name) 1.INJ MONOCEF 1MG IV/BD 2.IV FLUIDS NS @ 75ML/HR 3.INJ HAI SC PREMEAL/TID 4.INJ NPH SC PREMEAL/BD 5.INJ PAN 40MG IV/BD/BBF 6.INJ ZOFER 4MG IV/SOS 7.INJ PCM 1MG IV/SOS 8.TAB PCM 650MG PO/QID 9.SYP ASCORIL -LS 10ML PO/TID 10.STRICT I/O CHART 11.GRBS 7 PROFILE MONITORING 12.BP,PR,TEMP MONITORING 4TH HOURLY 13.POTASSIUM RICH DIET Advice at Discharge 1. TAB. TAMIM 200MG PO/BD X 3DAYS 2. INJ. HAI SC PRMEAL TID 14 UNITS-------14 UNITS------14 UNITS. 3.INJ. NPH SC PREMEAL BD 12U-------X-------12U 4.TAB. PAN 40 MG PO/BD BBF X 1WEEK 5.CIPLOX EAR DROPS 3DROPS-----3D----3D X 5D 6. OTIRIVIN N/D3D-----3D-----3D X 5D 7. STRICT DIABETIC DIET( EXPLAINED ) 8. HOUSE GRBS MONITORING. 9.TAB. ZOFER 4MG PO/SOS 10.TAB. PCM 650 MG PO/SOS

Patient outcome:

Good recovery at the time of discharge

Case 30:

70/F

Diagnosis ALTERED SENSORIUM SECONDARY TO MENINGITIS SECONDARY TO ? VIRAL PYREXIA (?DENGUE) (RESOLVED) SECONDARY TO HYPONATREMIA (RESOLVED) Case History and Clinical Findings

Patient came to casualty with chief complaints ofInvoluntary movements of B/L upper limbs and lower limbs since 1 dayAltered sensorium since 1 dayHOPI:Pt was apparently asymptomatic 5 days ago and then she developed fever which is of high grade associated with chills and rigors, body pains and was diagnosed to have dengue and was treated for the same in a private hospital.Pt count 30k-35k40k.Pt also had involuntary movements of B/L upper limbs and lower limbs.Pt is agitated and decreased talking since morningNo h/o tongue biteNo h/o uprolling of eye ballsNo h/o Vomiting, involuntary micturition, Bowel movementsNo h/o LOC, trauma, head injuryNo h/o SOB, chest painGCS at the time of presentation E3V2M5Past historyNot a k/c/o DM ,HTN,TB,epilepsy and asthmaChronic smoker (chutta)since 30years,stopped 1 year backToddy drinker (on and off),stopped 20years backH/O cataract surgery 1 year backNo h/o of any blood transfusionsno h/o any previous surgeriesNo known allergiesAt the time of admissionPatient is in altered sensorium with her GCS beingE3V1M5(eye opening on calling,inappropriate sounds,localising pain)Bp 160/100mmHgPR 65bpmSaturation 96%on room air(after 30 minutes after admission saturation 88% on room air,blood gas analysis was done and showed hypoxia and metabolic alkalosisRR-20 cpmGRBS-157 mg/dlTemp-97.5Spo2-96 % on 6 lts O2Neck stiffness was Presentbrudzinski sign was positiveUrea: 79mg/dLCreat:1.6mg/dLNa: 117mEq/LK:3.5mEq/LCl:74mEq/LHb: 15.6gm/dLTLC: 9700cells/cummPlt 78000cells/cummPT 24secINR 1.7APTT 48secUrinary electrolytesUNa:191Ucl:217Uk:39.8Serum osmolarity 251Personal history:Diet- MixedAppetiteGoodBowel and bladder movements- RegularSleep- AdequateAddictions-Chronic smoker (chutta)since 30years,stopped 1 year backToddy drinker (on and off),stopped 20years backFamily history:No significant family historyNo family history of Hypertension, Diabetes, TB, Asthma, SeizuresGeneral Physical Examination:Done after obtaining consent, in the presence of attend ant with adequate exposurePatient is irritablewell nourished and moderately builtPallorAbsentIcterus- MildCyanosis- AbsentClubbing- AbsentLymphadenopathy- AbsentEdemaAbsentVitalsTemperature- 97.5 FBlood pressure- 160/90 mm of HgPulse rate- 85 bpmRespiratory rate- 18 cpmSpO2- 96% at room airGRBS- 160 mg%Systemic Examination:Cardiovascular system:S1 and S2 sounds are heardNo abnormal murmersRespiratory system:Bilateral air entry is presentTrachea is centralNormal vesicular breath sounds are heardNo adventitious sounds are heardAbdominal Examination:Shape of Abdomen is scaphoidSoft and non tenderBowel sounds are heardNo palpable massHernial orifices are normalNo organomegalyCentral Nervous System:PupilsRight-sluggish reactive to lightLeft-cataracr surgery- done reactiveNeck rigidity +Brudzinski' sign +GCS-E2V2M5CNS-Power: Couldn’t be elicitedMoving all four limbs to painTONEU/L. Increased IncreasedL/L. Increased IncreasedTremors +Involuntary movements +Reflexes: Right. Left.Biceps. ++. ++Triceps. + ++Supinator + +Knee. ++. +Ankle + +Plantar- M M Investigation 1. HEMOGRAM 2/12/22 HB- 15.6 gm/dL

TLC- 9700 cells/cumm PLT- 78000 /cumm 3/12/22 HB- 14.9 gm/dL TLC- 13400 cells/cumm PLT- 80000 /cumm 4/12/22 HB- 13.0 gm/dL TLC- 10000 cells/cumm PLT- 1 Lakh /cumm 5/12/22 HB- 12.3 gm/dL TLC- 11000 cells/cumm PLT- 1.25 lakhs/cumm 6/12/22 HB- 12.2 gm/dL TLC- 13000 cells/cumm PLT- 1.86 lakhs/cumm 7/12/22 HB- 13.2 gm/dL TLC- 12000 cells/cumm PLT- 2.46 lakhs/cumm 2. ECG- NORMAL SINUS RHYTHM 3. CHEST XRAY PA VIEW- LVH NOTED 4. MRI BRAIN PLAINMILD CEREBRAL ATROPHY WITH EARLY SMALL VESSEL ISCHEMIC CHANGES 5. 2D ECHO

NO RWMA, PARADOXICAL IVS CONCENTRIC LVH + (1.35 CMS) MILD TO MODERATE AR +, TRIVIAL TR +; NO MR SCLEROTIC AV, NO AS/MS EF= 58%, RVSP- 35 MMHG GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION (+), NO PE IVC SIZE (0.8 CMS), COLLAPSING 6. URINE CULTURE AND SENSITIVITY REPORT- NO GROWTH 7. BLOOD CULTURE AND SENSITIVITY REPORT- NO GROWTH AFTER 24 HRS OF AEROBIC INCUBATION 8. CSF CULTURE AND SENSITIVITY REPORTGRAM STAIN- NO PUS CELLS, NO ORGANISMS SEEN ZN STAIN- NO ACID FAST BACILLUS SEEN INDIAN INK- NO FUNGAL ELEMENTS SEEN 9. CSF ANALYIS CSF SUGAR- 57 CSF PROTEIN- 15 CSF CHLORIDE- 19 CSF LDH- 180 CSF CELL COUNT COLOUR- COLOURLESS APPEARANCE- CLEAR QUANTITY- 0.5ML TOTAL COUNT- 21 CELLS/CUMM LYMPHOCYTES- 70% NEUTROPHILS- NIL RBC- NIL OTHERS- 30% MONOCYTES Treatment Given(Enter only Generic Name) 1. 3% NS @ 10 ML/HR 2. O2 SUPPLEMENTATION TO MAINTAIN SAT >92%

IVF NS, RL @ 50 ML/HR 4. RYLES FEED- PROTEIN MILK POWDER 100 ML 4TH HOURLY WATER 100 ML 2ND HOURLY 5. INJ. VIT K 2 AMP 6. SYP POTCHLOR 10 ML/RT/TID IN 1 GLASS OF WATER 7. INJ.DEXA 8 MG/IV/TID 8. INJ. MONOCEF 2 G/ IV/BD 9. INJ. OPTINEURON 1 AMP + 100 ML NS OVER 30 MIN 10. OINTMENT THROMBOPHOBE FOR L/A 11. MONITOR VITALS BP, RR, SAT, GRBS 12. STRICT I/O CHARTING 13. INFORM SOS Advice at Discharge 1. PLENTY OF ORAL FLUIDS 2. TAB. WYSOLONE 30 MG BD X 3 DAYS 3. TAB.TAXIM 200 MG/ PO/ BD X 3 DAYS 4. TAB. TOLVAPTAN 30 MG/ PO BD X 2 DAYS 5. OINT. THROMBOPHOBE FOR L/A

Patient outcome:

Good recovery at discharge

Case 31:

33/M

Diagnosis SEPTIC ENCEPHALOPATHY

ACUTE KIDNEY INJURY WITH MODS Case History and Clinical Findings A 32 YEAR OLD MALE, LORRY DRIVER BY OCCUPATION, RESIDENT OF NALGONDA CAME TO THE CASUALTY WITH THE CHIEF COMPLAINTS OF 1. PAIN ABDOMEN SINCE 10 DAYS 2. SOB SINCE 10 DAYS 3. B/L PEDAL EDEMA SINCE 10 DAYS 4. DECREASED URINE OUTPUT SINCE 1 DAY PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS AGO FOLLOWED BY HE DEVELOPED B/L PEDAL EDEMA WHICH IS OF PITTING TYPE INITIALLY ABOVE THE KNEES AND PROGRESSED TILL THIGH AND LATER TO ABDOMEN FOLLOWED BY WHICH HE DEVELOPED ABDOMINAL TIGHTNESS, PAIN ABDOME AND DIFFICULTY BREATHING SINCE 10 DAYS PAIN IN THE ABDOMEN WAS DIFFUSED TO WHOLE ABDOMEN AND GRADUALLY INCREASING INTENSITY AND IS SQUEEZING TYPE PAIN IS PERSISTENT THROUGHOUT THE DAY NO H/O RADIATION TO THE BACK H/O FEVER 10 DAYS AGO NO H/O NAUSEA ND VOMITINGS

NO AGGREVATING AND RELIEVING FACTORS PATIENT HAD A HISTORY OF DECREASED URINE OUTPUT SINCE 10 DAYS AND NO URINE OUTPUT SINCE 1 DAY AND YESTERDAY EVENING HE HAD A H/O FALL DUE TO GIDDINESS AND NO LOC H/O VOMITINGS FOR 5 DAYS, 5 TO 6 EPISODES OF VOMITINGS AND THE CONTENT WAS FOOD PARTICLES, IMMEDIATELY AFTER EATING ANYTHING BUT TOLERATING ONLY FLUIDS JVP RAISED NO H/O EVENING RISE OF TEMPERATURE, COUGH, NIGHT SWEATS NO HISTORY SUGGESTIVE OF HEMETEMESIS, MALENA, BLEEDING PER RECTUM NO PALPABLE MASS PER ABDOMEN PAST HISTORY NOT A KNOWN CASE OF DM, HTN, ASTHMA, TB, EPILEPSY NO SIMILAR COMPLAINTS IN THE PAST NO KNOWN ALLERGIES PERSONAL HISTORY DIET- MIXED APPETITE- DECREASED SINCE 10 DAYS BOWEL AND BLADDER MOVEMENTS- REGULAR SLEEP- ADEQUATE ADDICTIONS- CHRONIC ALCOHOLIC SINCE 15 YEARS CONSUMES WHISKY 90 ML/DAY CHRONIC SMOKER- BEEDI 1 PACK/DAY FAMILY HISTORY NO SIMILAR COMPLAINTS IN THE FAMILY GENERAL EXAMINATION DONE AFTER OBTAINING CONSENT IN THE PRESENCE OF ATEENDANT WITH ADEQUATE EXPOSURE PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE AND WELL ORIENTED TO TIME, PLACE AND PERSON HE IS WELL NOURISHED AND MODERATELY BUILT

VITALS TEMPERATURE- AFEBRILE BP- 80/60 MMHG PR- 88 BPM RR- 22 CPM Inspection Shape of the abdomen- Distended Umbilicus- everted Movements of abdominal wall- moves with respiration Skin is smooth, shiny No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites Palpation Inspectory findings are confirmed Tenderness is present in whole of the abdomen Guarding and rigidity present Mild hepatosplenomegaly Abdominal girth- 96.5 cms Percussion Resonant note is heard on the midline Auscultation Bowel sounds are decreased COURSE IN THE HOSPITAL

PATIENT WAS INITIALLY ON DIURETICS AS HIS URINE OUTPUT IS NIL AND INOTROPES WERE STARTED SIMULTANEOUSLY IN VIEW OF HYPOTENSION AND FLUIDS WERE GIVEN UPTO 500 ML FOR HIS URINE OUTPUT. EVEN THOUGH PATIENT DIDN'T PASSED URINE AND PATIENT CREATININE IS RAISING AND PATIENT CONDITION IS WORSENING AND PATIENT IS BECOMING DROWSY, PATIENT WAS TAKEN TO DIALYSIS ONCE HIS BLOOD PRESSURE STARTED IMPROVING ON INOTROPIC SUPPORT, AND HEMODIALYSIS WAS DONE AFTER TAKING NEPHROLOGIST CONSULTATION, AND PATIENT PASSED URINE POST DIALYSIS AND INOTROPES WERE TAPERED SLOWLY AND SUBSEQUENTLY PATIENT WAS TAKEN FOR SERIAL DIALYSIS, AND HIS PEDAL EDEMA GRADUALLY STARTED DECREASING AND PATIENT CONDITION GOT IMPROVED AND PATIENT IS HEMODYNAMICALLY STABLE AND PLANNED FOR DISCHARGE Investigation 1. USG ABDOMEN- MILD HEPATOMEGALY WITH GRADE 1 FATTY LIVER LEFT SIMPLE RENAL CORTICAL CYST 2. ECG- NO ABNORMALITY DETECTED 3. 2D ECHO (14/10/22) - DILATED RA/RV WITH SEVERE TRP WITH SEVERE PAHT (RESP- 70 MMHG) D SHAPE LEFT VENTRICLE PARADOXICAL IVS IAS- INTACT GOOD LV SYSTOLIC FUNCTION TRIVIAL APQ/MRQ DIASTOLIC DYSFUNCTION + IVC DILATED GROSSELY NO PE/LV CLOT DILATED PULMONARY ARTERY 2D ECHO (25/10/22) REVIEW NO RWMA MODERATE TR + TRIVIAL AR +/MR+ NO AS/MS EF = 55 RVSP= 38+10 = 48 MM GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION IVC SIZE (1.15 CMS) 4. X RAY- NO ABNORMALITY DETECTED Treatment Given(Enter only Generic Name) 1. Inj. Noradrenaline 2 amp in 50 ml NS@ 12 ml/hr to maintain SBP more than 120mmHg 2. Inj. Vasopressin 1 amp in 50 ml NS @ 2 ml/hr to maintain SBP more than 120 mmHG 3. Inj. PIPTAZ 7.5 gm iv stat 4. Inj. Zofer 4 mg/IV/BD 5. Inj. Calcium gluconate 10% ml over 10 minutes IV stat 6. Inj. Optineuron 1 amp in 100 ml NS/IV/OD 7. Inj. RANTAC 50 mg/ IV/OD 8. Syp. Lactulose 15 ml H/S 9. Nebulization 6th hrly 10. Inj. Dobutamine 1 amp in 46 ml NS @ 4 ml/hr 11.Inj. VITAMIN-K 1 amp in 10 ml NS /IV/OD 12.Tab. Doxycycline 100 mg/PO/BD 13. T. UDILIV 300 mg/PO/BD Advice at Discharge 1. TAB. FAROPENEM 300 MG/ PO /BD X 3 DAYS 2.TAB. RANTAC 150 MG/ PO/ BD X 3 DAYS 3.THROMBOPHOBE OINTMENT FOR L/A 4. SALT RESTRICTION <2G/DAY 5.FLUID RESTRICTION <1.5 G/DAY

Patient outcome:

Good recovery

Case 32:

85 ,F

ALTERED SENSORIUM SECONDARY TO ? CO2 NARCOSIS MIXED (RESPIRATORY AND METABOLIC) ACIDOSIS COMMUNITY ACQUIRED PNEUMONIA (LEFT LOWER LOBE CONSOLIDATION) B/L PLEURAL EFFUSION (LEFT >RIGHT) HYPERKALEMIA (RESOLVED) TYPE 2 RESPIRATORY FAILURE MODERATE TO SEVERE PAH TYPE 1 RIGHT TROCHANTERIC FRACTURE GRADE 2 AND GRADE 4 BEDSORE OVER RIGHT GLUTEAL REGION. Case History and Clinical Findings C/O SHORTNESS OF BREATH SINCE 3 DAYS HOPI: PATIENT WAS APPARENTLY ALRIGHT 20 DAYS BACK, AND HAD H/O GIDDINESS AND H/O FALL AND SUSTAINED INJURY TO RIGHT HIP AND WAS DIAGNOSED WITH RIGHT INTERTROCHANTERIC FRACTURE. PATIENT WAS ADMITTED AND SYMPTOMATIC TREATMENT WAS GIVEN. PATIENT WAS BEDRIDDEN AFTER THE FRACTURE AND DEVELOPED GRADE 2-3 BEDSORES OVER RT GLUTEAL REGION WHICH HAS BEEN NOTICED YESTERDAY. PATIENT DEVELOPED GENERALISED WEAKNESS AND HAD NO FOOD INTAKE SINCE YESTERDAY. SHE DEVELOPED SOB EVEN ON REST, ORTHOPNEA +, PND+. NO RELIEVING FACTORS NOTED , AGGRAVATED ON TALKING. H/O COUGH WITH MUCOID EXPECTORATION YESTERDAY.

NO C/O FEVER, COLD, BURNING MICTURITION, CHEST PAIN, PALPITATIONS, DECREASED URINE OUTPUT, PEDAL EDEMA. PAST HISTORY : NOT A K/C/O HTN, DM, CVA, CAD, TB, EPLIEPSY, ASTHMA. GENERAL EXAMINATION: PATIENT IS C/C/C BP= 140/80 MMHG PR = 118 BPM RR = 20 CPM SPO2 = 80 % TEMP = 99.2 F GRBS = 114 MG/DL SYSTEMIC EXAMINATION: RS = BAE+, NVBS +, B/L CREPTS +, MA, IAA CVS = S1 S2 +, NO MURMURS P/A = SOFT, NONTENDER Investigation

NameValueRangeNameValueRangeCOMPLETE BLOOD PICTURE (CBP) 16-08-2023 02:38:PM HAEMOGLOBIN8.8 gm/dl15.0-12.0 gm/dlTOTAL COUNT15700 cells/cumm10000-4000 cells/cummNEUTROPHILS83 %80-40 %LYMPHOCYTES07 %40-20 %EOSINOPHILS01 %6-1 %MONOCYTES09 %10-2 %BASOPHILS00 %2-0 %PLATELET COUNT6.0SMEARNormocytic normochromic Anemia with neutrophilic leucocytosisRFT 16-08-2023 02:38:PM UREA52 mg/dl50-17 mg/dlCREATININE1.0 mg/dl1.2-0.6 mg/dlURIC ACID4.3 mg/dl6-2.6 mg/dlCALCIUM9.2 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.3 mg/dl4.5-2.5 mg/dlSODIUM139 mEq/L145-136 mEq/LPOTASSIUM6.0 mEq/L5.1-3.5 mEq/LCHLORIDE102 mEq/L98-107 mEq/LABG 16-08-2023 02:39:PM PH7.233PCO252.8PO278.6HCO321.5St.HCO319.6BEB-5.8BEecf-4.9TCO245.6O2 Sat94.2O2 Count15.1RFT 16-08-2023 06:22:PM UREA50 mg/dl50-17 mg/dlCREATININE1.0 mg/dl1.2-0.6 mg/dlURIC ACID4.2 mg/dl6-2.6 mg/dlCALCIUM10.2 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.5 mg/dl4.5-2.5 mg/dlSODIUM138 mEq/L145-136 mEq/LPOTASSIUM5.6 mEq/L5.1-3.5 mEq/LCHLORIDE105 mEq/L98-107 mEq/LLIVER FUNCTION TEST (LFT) 16-08-2023 06:22:PM Total Bilurubin0.69 mg/dl1-0 mg/dlDirect Bilurubin0.20 mg/dl0.2-0.0 mg/dlSGOT(AST)12 IU/L31-0 IU/LSGPT(ALT)11 IU/L34-0 IU/LALKALINE PHOSPHATE521 IU/L141-53 IU/LTOTAL PROTEINS5.8 gm/dl8.3-6.4 gm/dlALBUMIN2.61 gm/dl4.6-3.2 gm/dlA/G RATIO0.82HBsAg-RAPID16-08-2023 06:24:PMNegative Anti HCV Antibodies - RAPID16-08-2023 06:24:PMNon Reactive RFT 17-08-2023 12:39:AM UREA48 mg/dl50-17 mg/dlCREATININE0.8 mg/dl1.2-0.6 mg/dlURIC ACID3.1 mg/dl6-2.6 mg/dlCALCIUM9.6 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.4 mg/dl4.5-2.5 mg/dlSODIUM136 mEq/L145-136 mEq/LPOTASSIUM5.9 mEq/L5.1-3.5 mEq/LCHLORIDE104 mEq/L98-107 mEq/LRFT 18-08-2023 12:38:AM UREA50 mg/dl50-17 mg/dlCREATININE1.0 mg/dl1.2-0.6 mg/dlURIC ACID4.5 mg/dl6-2.6 mg/dlCALCIUM10.0 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.5 mg/dl4.5-2.5 mg/dlSODIUM142 mEq/L145-136 mEq/LPOTASSIUM6.0 mEq/L5.1-3.5 mEq/LCHLORIDE102 mEq/L98-107 mEq/LCOMPLETE URINE EXAMINATION (CUE) 18-08-2023 08:57:AM COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN+SUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS3-6EPITHELIAL CELLS2-2RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilABG 18-08-2023 11:08:AM PH7.24PCO251.8PO257.1HCO321.6St.HCO319.8BEB-5.5BEecf-4.6TCO245.8O2 Sat88.0O2 Count14.1SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 1808-2023 05:26:PM SODIUM137 mEq/L145-136 mEq/LPOTASSIUM4.3 mEq/L5.1-3.5 mEq/LCHLORIDE102 mEq/L98-107 mEq/LCALCIUM IONIZED1.49 mmol/Lmmol/LRFT 19-08-2023 01:06:AM UREA37 mg/dl50-17 mg/dlCREATININE0.9 mg/dl1.2-0.6 mg/dlURIC ACID4.1 mg/dl6-2.6 mg/dlCALCIUM10.2 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.1 mg/dl4.5-2.5 mg/dlSODIUM136 mEq/L145-136 mEq/LPOTASSIUM5.0 mEq/L5.1-3.5 mEq/LCHLORIDE102 mEq/L98-107 mEq/LABG 19-08-2023 05:25:PM PH7.23PCO249.1PO266.0HCO320.1St.HCO318.7BEB-7.0BEecf6.1TCO242.2O2 Sat91.6O2 Count16.3ABG 19-08-2023 05:26:PM PH7.24PCO246.0PO244.6HCO319.2St.HCO318.0BEB-7.6BEecf-6.9TCO240.5O2 Sat79.7O2 Count13.3RFT 20-08-2023 12:03:AM UREA45 mg/dl50-17 mg/dlCREATININE1.1 mg/dl1.2-0.6 mg/dlURIC ACID4.7 mg/dl6-2.6 mg/dlCALCIUM9.4 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.2 mg/dl4.5-2.5 mg/dlSODIUM136 mEq/L145-136 mEq/LPOTASSIUM5.2 mEq/L5.1-3.5 mEq/LCHLORIDE99 mEq/L98-107 mEq/LABG 20-08-2023 10:57:PM PH7.13PCO248.8PO283.7HCO315.8St.HCO314.7BEB-12.1BEecf-11.6TCO235.8O2 Sat93.1O2 Count10.3RFT 21-08-2023 04:39:AM UREA59 mg/dl50-17 mg/dlCREATININE1.0 mg/dl1.2-0.6 mg/dlURIC ACID5.0 mg/dl6-2.6 mg/dlCALCIUM10.0 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.8 mg/dl4.5-2.5 mg/dlSODIUM139 mEq/L145-136 mEq/LPOTASSIUM5.0 mEq/L5.1-3.5 mEq/LCHLORIDE99 mEq/L98-107 mEq/LABG 21-08-2023 04:39:AM PH6.94PCO255.7PO2151HCO311.5St.HCO39.9BEB-19.2BEecf-18.4TCO227.9O2 Sat93.6O2 Count9.6BLOOD UREA22-08-2023 03:48:AM59 mg/dl50-17 mg/dlSERUM CREATININE22-08-2023 03:48:AM1.0 mg/dl1.2-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 22-08-2023 03:48:AM SODIUM138 mEq/L145-136 mEq/LPOTASSIUM4.7 mEq/L5.1-3.5 mEq/LCHLORIDE101 mEq/L98-107 mEq/LCALCIUM IONIZED1.20 mmol/Lmmol/LSERUM ELECTROLYTES (Na, K, C l) AND

SERUM IONIZED CALCIUM 22-08-2023 10:50:AM SODIUM134 mEq/L145-136 mEq/LPOTASSIUM4.9 mEq/L5.1-3.5 mEq/LCHLORIDE98 mEq/L98-107 mEq/LCALCIUM IONIZED1.21 mmol/Lmmol/LABG 23-08-2023 12:48:AM PH7.23PCO245.7PO232.9HCO318.9St.HCO317.7BEB-7.8BEecf-7.3TCO240.9O2 Sat64.7O2 Count9.1ABG 23-08-2023 02:30:AM PH7.14PCO262.9PO244.4HCO320.9St.HCO317.5BEB8.1BEecf-6.7TCO246.0O2 Sat75.1O2 Count11.6ABG 23-08-2023 02:48:AM PH7.21PCO256.2PO222.5HCO321.9St.HCO318.7BEB-5.8BEecf-4.8TCO247.5O2 Sat39.6O2 Count6.2BLOOD UREA23-08-2023 05:03:AM61 mg/dl50-17 mg/dlSERUM CREATININE23-08-2023 05:03:AM1.1 mg/dl1.2-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 23-08-2023 05:03:AM SODIUM137 mEq/L145-136 mEq/LPOTASSIUM4.8 mEq/L5.1-3.5 mEq/LCHLORIDE99 mEq/L98-107 mEq/LCALCIUM IONIZED1.20 mmol/Lmmol/LABG 23-08-2023 06:47:AM PH7.13PCO268.1PO275.9HCO321.8St.HCO318.3BEB-7.4BEecf-6.1TCO248.7O2 Sat92.9O2 Count12.5ABG 24-08-2023 12:24:AM PH7.07PCO277.0PO240.9HCO321.6St.HCO316.6BEB-9.3BEecf-7.2TCO248.6O2 Sat72.5O2 Count11.0ABG 24-08-2023 07:28:AM PH7.07PCO274.7PO236.2HCO321.0St.HCO316.0BEB10.1BEecf-7.7TCO246.8O2 Sat68.8O2 Count11.6 2D ECHO REPORT:-TACHYCARDIA-NO RWMA-MODERATE TO SEVERE TR WITH PAH( 52 + 20 = 72 MMHG)-MILD TO MODERATE AR +, MILD TO MODERATE MR +-SCLEROTIC AV-NO AS/MS-EF = 58-GOOD LV SYSTOLIC FUNCTION-DIASTOLIC DYSFUNCTION +, NO PE-IVC SIZE (1.62 CM), MILD DILATED COLLAPSING-MILD DIFFUSED R.V. (4.02 CM)-DILATED RA / LA-IAS --- ANEURYSM Treatment Given(Enter only Generic Name) 1. OXYGEN SUPPLEMENTATION @ 2 L /HR 2. INTERMITTENT NIV SUPPORT 3. RT FEEDS --- WATER (100 ML) 2ND HOURLY, MILK (200ML) 4TH HOURLY

4. IV FLUIDS NS @ 50ML/HR 5. INJ. PIPTAZ 2.23 GM/IV/BD 8AM AND 8PM 6. INJ. CLINDAMYCIN 600MG/ IV/BD 8AM AND 8 PM 7. INJ. HAI IOU IN 25D IV /SOS (IF POTASSIUM >5.2) 8. INJ. CLEXANE 49 MG S/C OD 9.TAB. AZITHROMYCIN 500 MG RT/ OD 10. NEB IPRAVENT + BUDECORT 6TH HOURLY 11. INJ. MAGNEX FORTE 1.5 GM 12. REGULAR DRESSING FOR BEDSORE. 13. PASSIVE PHYSIOTHERAPY 14. POSITION CHANGE 2 ND HOURLY 15. MONITAL VITALS STRICTLY Advice at Discharge DEATH SUMMARY : A 85 YEAR OLD FEMALE, K/CO RIGHT INTERTROCHANTERIC FRACTURE, SINCE 20 DAYS ON CONSERVATIVE MANAGEMENT WITH GRADE 2 AND GRADE 4 BEDSORE ON THE RIGHT GLUTEAL REGION SINCE 10 DAYS, PRESENTED TO THE HOSPITAL WITH C/O SHORTNESS OF BREATHSINCE 2-3 DAYS WHICH WAS PRESENT EVEN ON REST (GRADE 4 MMRC). ABG SHOWED MIXED ACIDOTIC PATTERN. SPO2 WAS 98% ON 4 L O2. CTPA IN V/O PULMONARY EDEMA WAS DONE WHICH SHOWED CONSOLIDATION IN LATERAL ASPECT OF LEFT LOWER LUNG LOBE. SEGMENTAL ATELECTASIS IN APICO - POSTERIOR SEGMENT FO LEFT LOWER LOBE WITH B/L PLEURAL EFFUSION ( MILD ON RIGHT, MODERATE ON LEFT SIDE). IV ANTIBIOTICS WERE STARTED ACCORDINGLY. PATIENT WAS IN TYPE 2 RESPIRATORY FAILURE WITH MODERATE TO SEVERE PAH TYPE 1. INITIALLY SPO2 WAS 98% ON 4 L OXYGEN, GRADUALLY THE OXYGEN REQUIREMENT INCREASED TO 8-9 L OXYGEN. INTERMITTENT BIPAP SUPPORT WAS GIVEN, EVENTUALLY PATIENT WAS ON NON INVASIVE VENTILLATION WITH PRESSURE SUPPORT I/V/O LOW GCS AND LOW SATURATION, TYPE 1 RESPIRATORY FAILURE. PATIENT WAS INTUBATED ON 24/8/23 AND 7MM TUBE WAS PLACED AND CONFIRMED WITH 5 POINT AUSCULTATION. IMMEDIATELY AFTER INTUBATION, PATIENT HAD SUDDEN FALL IN SATURATION AND PULSE AND PATIENT WENT INTO CARDIAC ARREST AROUND 11.45 AM ON 24/08/23. CPR WAS INITIATED ACCPRDING TO ACLS GUIDELINES AND CONTINUED FOR AROUND 30 MINS. INSPITE OF ABOVE EFFORTS, PATIENT COULD NOT BE REVIVED. PATIENT WAS DECLARED DEAD AT 12.19 PM.

IMMEDIATED CAUSE OF DEATH : TYPE 1 RESPIRATORY FAILURE ANTECEDANT CAUSE OF DEATH : SYNPNEUMONIC EFFUSION CHRONIC TYPE 2 RESPIRATORY FAILURE, MODERATE TO SEVERE PAH TYPE 1 RIGHT INTERTROCHANTERIC FRACTURE GRADE 2 AND GRADE 4 BEDSORE OVER RIGHT GLUTEAL REGION.

Patient outcome:

Patient DIED in the hospital

Case 33:.

75/F

Diagnosis ALTERED SENSORIUM SECONDARY TO ? SEPTIC ENCEPHALOPATHY WITH UTI ? TB MENINGO ENCEPHALIIS WITH PRE RENAL AKI ON CKD WITH HEALING GLUTEAL ABSCESS WITH HTN WITH LATE ONSET PSYCHOSIS WITH ANEMIA OF CHRONIC DISEASE WITH GRADE II BEDSORE WITH HYPOKALEMIA Case History and Clinical Findings PT C/O FEVER,ALTERED SENSORIUM,LOSS OF APPETITE SINCE 2 DAYS. PT WAS APPARANTLY ASYMPTOMATIC 2 DAYS AGO THEN SHE HAD FEVER WHICH WAS HIGH GRADE, NOT ASSOCIATED WITH CHILLS, RIGORS.RELIEVED WITH MEDICATION.NO DIURNAL VARIATION. ALTERED SENSORIUM SINCE 2 DAYS. IRRELEVANT BLACK OUT , NOT ABLE IDENTIFY ATTENDERS. NO H/O LOSS OF CONSCIOUSNESS,INVOLUNTARY MOVEMNENTS, WEAKNESS IN BOTH UPPER AND LOWER LIMBS.LOSS OF APPETITE PRESENT N/H/O CHEST PAIN,SOB,PALPITATIONS,PEDAL EDEMA. N/H/O COUGH,BURNING MICTURITION K/C/O HTN ON TAB.ATENOLOL K/C/O CKD ON CONSERVATIVE MANAGEMENT K/C/O AKION CKD SECONDARY TO RUPTURED GLUTEAL ABSCESS WITH K/C/O LATE ONSET PSYCHOSIS H/O BLOOD TRANSFUSION- FFP TRANSFUSION GENERAL EXAMINATION

PT IS DROWSY AROUSABLE WITH DEEP PAIN STIMULATION NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,OEDEMA. BP: 100/60MMHG PR : 98BPM RR : 24 CPM SPO2 : 97% GRBS : 148 MG% I/O : 2500/1300 SYSTEMIC EXAMINATION CVS : S1 S2 HEARED ,NO MURMURS RS: BAE +, NVBS HEARD PA : SOFT,NT CNS : GCS : E2 V2 M4 POWER UL AND LL NOT ELICITABLE TONE UL AND LL NORMAL ON BOTH RT AND LT SIDE REFLEXES B T S K A P RT 2+ 2+ 1+ 2+ 1+ ELEVATED LT 2+ 2+ 1+ 2+ 1+ ELEVATED Investigation 24/8/23 HB 8.6 TLC 21,000 N/L/E/M/B 69/22/1/8/0 PLT 3.32 LAKHS 25/8/23 HB 14 TLC 16,400 N/L/E/M/B 83/7/1/9/0 PLT 4.85 LAKHS SR CR 3.1 BLOOD UREA 109 NA 140 K 3.8

CL 101 SR CA 10.1 LUMBAR PUNCTURE DONE CSF : SUGAR 61 PROTEIN 15 AOA 15 26/8/23 HB 8.4 TLC 32,200 N/L/E/M/B 87/4/0/9/0 PLT 3 LAKHS SR CR 2.7 BLOOD UREA 106 NA 139 K 4.1 CL 101 27/8/23 HB 8.2 TLC 28,000 N/L/E/M/B 90/7/3/0 PLT 2 LALHS SR CR 2.5 BLOOD UREA 111 NA 138 K 4.2 CL 101 28/8/23 HB 8.6 TLC 27,000 N/L/E/M/B 88/6/0/6/0 PLT 1.8 LAKHS SR CR 2.2 BLOOD UREA 115 NA 143

K 3.3 CL 98 TB 1.20 DB 20 AST 13 ALT 12 29/8/23 HB 8.1 TLC 28,400 N/L/E/M/B 90/6/1/3/0 PLT 2.3LAKHS 30/8/23 TLC 58000 31/8/23 HB 8.4 TLC 70,000 N/L/E/M/B 92/5/0/3/0 PLT 2.7 LACS 1/9/23 HB 7.4 TLC 60,000 N/L/E/M/B 92/5/0/3/0 PLT 2.0 LAKHS ECG WAS DONE CHEST X RAY WAS DONE 2D ECHO ON 24/8/23 MILD AR +, MILD TR + WITH PAH NO RWMA . NO AS/MS.SCLEROTIC AV GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION . NO PE REVIEW 2D ECHO ON 29/8/23 MILD GLOBAL HYPOKALEMIA MILD TRWITH PAH , MODERATE AR , NO MR SCLEROTIC AV NO AS/MS

EF= 52 FAIR LV FUNCTIONS DIASTOLIC DYSFUNCTION , NO PE IVC SIZE NON COLLAPSING USG DONE 25/8/23 B/L GRADE I-II RPD CHANGES MRI BRAIN PLAIN WAS DONE 29/8/23 DIFFUSE CEREBRAL ATROPHY CHRONIC SMALL VESSEL ISCHEMICCHANGES OLD LACUNAR INFARCTS IN RT CAUDATE AND RT LENTIFORM NUCLEUS. Treatment Given(Enter only Generic Name) RT FEEDS : 100ML WATER 2ND HRLY,200ML MILK 4 TH HRLY IV FLUIDS UO+ 30ML /HR INJ. MEROPENEM 500MG /IV/BD INJ. PAN 4O MG/IV/OD T. OROFER XT / OD INJ.CLEXANE 40MG/SC/OD SYP.POTLOR 15ML /RT/TID T.NODOSIS 500MG /RT/OD INJ.OPTINEURON 1AMP /NS BP,PR,RR,SPO2 MONITORING 2ND HRLY TEMP MONITORING 4 TH HRLY STRICT I/O CHARTING FREQUENT POSITION CHANGE REGULAR DRESSING OF ABSCESS ,BEDSORE Advice at Discharge RT FEEDS : 100ML WATER 2ND HRLY,200ML MILK 4 TH HRLY IV FLUIDS UO+ 30ML /HR INJ. MEROPENEM 500MG /IV/BD INJ. PAN 4O MG/IV/OD T. OROFER XT / OD INJ.CLEXANE 40MG/SC/OD SYP.POTLOR 15ML /RT/TID T.NODOSIS 500MG /RT/OD INJ.OPTINEURON 1AMP /NS Page-5 REGULAR DRESSING OF ABSCESS ,BEDSORE

Follow Up REFERRED TO HIGHER CENTRE NOTES PATIENT AND PATIENT ATTENDERS HAVE BEEN EXPLAINED ABOUT PTS CONDITION THAT IS ? SEPTIC ENCEPHALOPATHY ?UTI? TB MENINGO ENCEPHALIIS WITH PRE RENAL AKI ON CKD WITH HEALING GLUTEAL ABSCESS WITH HTN WITH LATE ONSET PSYCHOSIS WITH ANEMIA OF CHRONIC DISEASE WITH GRADE II BEDSORE WITH HYPOKALEMIA. PT HAS BEEN REFERRED TO HIGHER CENTRE IN VIEW OF HEMATO ONCOLOGY OPINION.

Patient outcome:

DIED AT HOME

Case. 34:

60/F

Diagnosis SEPTIC ENCEPHALOPATHY

SEPTIC SHOCK WITH AKI WITH LEFT LOWER LIMB DVT Case History and Clinical Findings PATIENT WAS BROUGHT TO CASUALITY WITH C/O PAIN ABDOMEN SINCE LAST MIGHT, DECREASED URINE OUTPUT SINCE LAST NIGHT HISTORY OF PRESENT ILLNESS:PATIENT WAS APPARENTLY NORMAL 1 DAY BACK THEN DEVELOPED PAIN ABDOMEN DRAGGING TYPE NON RADIATING LOCALISED TO UMBILICAL REGION ASSOCIATED WITH 2 EPISODES OF VOMITINGS WATERY NON BILIOUS NON PRTOJECTILE WITH FOOD PARTICLES AS CONTENTS C/O DECREASED URINE OUTPUT SINCE LAST NIGHT H/O FEVER 3 DAYS BACK HIGH GRADE INTERMITTENT ASSOCIATED WITH CHILLS AND RIGORS RELIEVED BY MEDICATION C/O PAIN IN LEFT LOWER LIMB, SWELLING PRESENT, PITTING TYPE, EXTENDING UPTO THE KNEE, TENDERNESS PRESENT C/O SHORTNESS OF BREATH SINCE LAST NIGHT NO C/O CHESTPAIN,PALPITATIONS, ORTHOPNEA, PND, LOOSE STOOLS AND FACIAL PUFFINESS PAST HISTORY:PATIENT IS A K/C/O HYPERTENSION SINCE 5 YEARS USING TAB.ATENOLOL 50MG OD

N/K/C/O DM, TB, EPILEPSY, CVA, CAD, THYROID DISORDERS PERSONAL HISTORY: APPETITE - NORMAL BOWELS - REGULAR MICTURITION - NORMAL NO ALLERGIES FAMILY HISTORY : NO SIGNIFICANT FAMILY HISTORY PHYSICAL EXAMINATION: NO PALLOR , CYANOSIS , ICTERUS , CLUBBING , LYMPHADENOPATHY , OEDEMA , MALNUTRTION , VITALS : TEMP - AFEBRILE PR - 80BPM RR - 26CPM BP - 90/60 MMHG SPO2 - 98% GRBS - 109MG/DL SYSTEMIC EXAMINATION : CVS - NO MURMURS , NO THRILLS , S1 AND S2 HEARD RR - NO DYSPNEA , WHEEZING , BREATH SOUNDS - VESICULAR , ADVENTITIOUS SOUNDS NO ABDOMEN- SHAPE : SCAPHOID , NO TENDERNES , NO PALPABLE MASS , NORMAL HERNIAL ORIFICES , NO FREE FLUID , NO BRUITS , LIVER AND SPLLEN NOT PALPABLE , BOWEL SOUNDS - YES , CNS - NO FOCAL AND NEUROLOGICAL DEFICITS Investigation BLOOD UREA29-10-2023 12:22:PM92 mg/dl 42-12 mg/dl SERUM CREATININE29-10-2023 12:22:PM4.7 mg/dl 1.1-0.6 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 29-10-2023 12:22:PMSODIUM135 mEq/L 145-136 mEq/L POTASSIUM3.6 mEq/L 5.1-3.5 mEq/L CHLORIDE101 mEq/L 98-107 mEq/L CALCIUM IONIZED1.13 mmol/L mmol/L COMPLETE URINE EXAMINATION (CUE) 29-10-2023 03:47:PMCOLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010 ALBUMIN ++++ SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 2-4 EPITHELIAL CELLS 1-2 RED BLOOD CELLS 2-4 CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil BLOOD UREA29-10-2023 03:47:PM93 mg/dl 42-12 mg/dl SERUM CREATININE29-10-2023 03:47:PM4.7 mg/dl1.1-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 29-10-2023 03:47:PMSODIUM137 mEq/L 145-136 mEq/L POTASSIUM3.6 mEq/L 5.1-3.5 mEq/L CHLORIDE101 mEq/L 98-107 mEq/L CALCIUM IONIZED1.01 mmol/L mmol/L LIVER FUNCTION TEST (LFT) 29-10-2023 03:47:PM Total Bilurubin0.66 mg/dl 1-0 mg/dl Direct Bilurubin0.17 mg/dl 0.2-0.0 mg/dl SGOT(AST)25 IU/L 31-0 IU/L SGPT(ALT)11 IU/L 34-0 IU/L ALKALINE PHOSPHATE186 IU/L 141-53 IU/L TOTAL PROTEINS4.8 gm/dl 8.3-6.4 gm/dl ALBUMIN2.58 gm/dl 4.6-3.2 gm/dl A/G RATIO1.16

Treatment Given(Enter only Generic Name) IV FLUIDS NS,DNS @ 50ML/HR INJ.METROGYL 500MG IV/TID INJ.NORADRENALINE 4ML+46ML NS @ 4ML/HR INCREASE/DECREASE TO MAINTAIN MAP>_65MMHG INJ.PAN 40MG IV/OD INJ.ZOFER 4MG IV/BD INJ.PIPTAZ 4.5MG IV/STAT TO INJ.PIPTAZ 2.25MG IV/TID NBM TILL FURTHER ORDERS INJ.NEOMOL 1GM IV/SOS IF TEMP >_101F MONITOT VITALS INFORM SOS Advice at Discharge PATIENTS ATTENDANTS HAE BEEN EXPLAINED ABOUT THE CONDITION OF THE PATIENT I.E, SEPTIC SHOCK WITH AKI WITH LEFT LOWE LIMB DVT AND THE NEED FOR FURTHER HOSPITALIZATION AND TREATMENT BUT PATIENTS ATTENDANTS ARE NOT WILLING FOR FURTHER HOSPITAL STAY. INSPITE OF EXPLAINING ALL COMPLICATIONS AND OUTCOMES OF THE PATIENT FOR NOT RECIEVING THE TREATMENT PATIENTS ATTENDANTS ARE WILLING TO TAKE THE PTIENT AND THE PATIENT HAS LEFT AGAINST MEDICAL ADVICE AND WANTED TO GO TO ANOTHER HOSPITAL AS THEY STAY IN DIFFERENT CITY.

Patient outcome:

DIED on followup

Case 35:

55/M

Diagnosis

SEPTIC ENCEPHALOPATHY

HEART FAILURE WITH MID RANGE EJECTION FRACTION( EF 44%) WITH RIGHT LOWER LOBE COLLAPSE WITH BRONCHIECTASIS WITH RIGHT MIDDLE LOBE PLEURAL EFUSION WITH CHRONIC PANCREATITIS WITH SEPSIS WITH GRADE 2 BED SORE WITH K/C/O DM II SINCE 20 YEARS WITH K/C/O CAD-S/P: PTCA DONE 2 YEARS AGO D9-S/P: TRACHEOSTOMY Case History and Clinical Findings PATIENT CAME WITH C/O LOWER BACK ACHE SINCE 3 WEEKS RADIATING TO LEFT LOWER LIMB HOPI:PATIENT WAS APPARENTLY ASYMPTOMATIOC 3 WEEKS BACK SINCE THEN, PATIENT COMPLAINTS OF LOWER BACK ACHE WHICH IS SUDDEN ONSET,NON PROGRESSIVE,AGRAVATES ON MOVEMENT RELEIVES ON REST H/O TRAUMA(SLIP AND FALL FROM STEPS) 3 WEEKS BACK ,WAS TAKEN TO OUTSIDE HOSPITAL FOUND TO HAVE L5 BURST FRACTURE ON CT PELVIS AND CAME HERE FOR FURTHER MANAGEMENT NO H/O LIFTING OF HEAVY WEIGHTS,FEVER BURNING MICTURITION BOWEL AND BLADDER INCONTINENCE PAST HISTORY OF RIGHT PROXIMAL FEMUR FRACTURE AND DONE IMILN 10 YEARS BACK. H/O PTCA DONE ONE AND HALF YEAR BACK AND IS ON REGULAR MEDICATION K/C/O DM II SINCE 20 YEARS AND IS ON T. METFORMIN 500 MG + T. VOGLIBOSE 0.2 MG + T. GLIMIPERIDE 2 MG

GENERAL EXAMINATION: PATIENT IS CONSCIOUS,NON COHERENT AND NON CO OPERATIVE NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS,EDEMA AND LYMPHADENOPATHY VITALS: TEMP:AFEBRILE BP: 110/80MMHG PR:80BPM RR:18CPM SYSTEMIC EXAMINATION: CVS: S1,S2+; NO MURMURS CNS:NAD RS:NVBS + P/A : SOFT,NON TENDER B/L OF LS SPINE: SKIN: NORMAL SWELLING: ABSENT TENDERNESS: PRESENT AT LUMBAR REGION TRACHEOSTOMY WAS DONE ON 6/9/23 BLOOD TRANSFUSION WAS DONE ON 12/9/23 PULMONOLOGY REFERRAL WAS DONE ON 30/8/23 AND ADVISED FOR CT CHEST AND INDUCED SPUTUM FOR CBNAAT AND CULTURE SENSITIVITY NEPHROLOGY REFERRAL WAS DONE ON 2/9/23 AND ADVISED FOR HAEMODIALYSIS PULMONOLOGY REFERRAL WAS DONE ON 2/9/23 AND ADVISED FOR USG GUIDED TAP AND ICD PLACEMENT SURGERY REFERRAL WAS DONE 4/9/23 AND ADVISED FOR ASEPTIC DRESSINGS, CHANGE OF POSITION 4 HOURLY AND ALPHA BED SURGERY REFERRAL WAS DONE 6/9/23 AND ADVISED FOR ASEPTIC DRESSINGS, CHANGE OF POSITION 2 HOURLY AND ALPHA BED Investigation RFT 29-08-2023 01:11:PM

UREA 77 mg/dl 42-12 mg/dl CREATININE 1.1 mg/dl 1.3-0.9 mg/dl URIC ACID 2.9 mg/dl 7.2-3.5 mg/dl CALCIUM 8.8 mg/dl 10.2-8.6 mg/dl PHOSPHOROUS 4.8 mg/dl 4.5-2.5 mg/dl SODIUM 121 mEq/L 145-136 mEq/L POTASSIUM 4.6 mEq/L 5.1-3.5 mEq/L CHLORIDE 95 mEq/L 98-107 mEq/L Page-3 LIVER FUNCTION TEST (LFT) 29-08-2023 01:11:PM

Total Bilurubin 0.76 mg/dl 1-0 mg/dl Direct Bilurubin 0.19 mg/dl 0.2-0.0 mg/dl SGOT(AST) 11 IU/L 35-0 IU/L SGPT(ALT) 13 IU/L 45-0 IU/L ALKALINE PHOSPHATE 321 IU/L 128-53 IU/L TOTAL PROTEINS 5.0 gm/dl 8.3-6.4 gm/dl ALBUMIN 2.59 gm/dl 5.2-3.5 gm/dl A/G RATIO 1.02 HBsAg-RAPID29-08-2023 01:11:PM

Negative Anti HCV Antibodies - RAPID29-08-2023 01:11:PM Non Reactive COMPLETE BLOOD PICTURE (CBP) 29-08-2023 01:11:PM HAEMOGLOBIN 9.0 gm/dl 17.0-13.0 gm/dl TOTAL COUNT 15300 cells/cumm 10000-4000 cells/cumm NEUTROPHILS 87 % 80-40 % LYMPHOCYTES 10 % 40-20 % EOSINOPHILS 01 % 6-1 % MONOCYTES 02 %mmol/L SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 30-08-2023 03:35:PM SODIUM 124 mEq/L 145-136 mEq/L POTASSIUM 4.4 mEq/L 5.1-3.5 mEq/L CHLORIDE 94 mEq/L 98-107 mEq/L CALCIUM IONIZED 1.12 mmol/L mmol/L ABG 30-08-2023 04:29:PM PH 7.34 PCO2 31.4 PO2 58.4 HCO3 16.7 St.HCO3

10-2 % BASOPHILS 00 % 2-0 %

HEMOGLOBIN: 6.2 MG/DL TLC: 19,200 CELLS/CUMM PLT: 1.5 LAKHS/CUMM 2D ECHO (30/8/23)- TACHYCARDIA, MILD LHF-RWMA; APEX, ANTERIOR WALL AND LATERAL WALL HYPOKINESIA- TRIVIAL MR/AR, NO TR- SCLEROTIC AV, NO AS/MS- EF= 44%, MODERATE LV DYSFUNCTION- NO DIASTOLIC DYSFUNCTION, NO PAH/PE HRCT OF CHEST (31/8/23)- RIGHT LOWER LOBE COLLAPSE WITH BRONCHIECTASIS- FOCI OF CONSOLIDATION IN RIGHT MIDDLE LOBE, LINGULA AND APICAL SEGMENT OF LEFT LUNG LOWER LOBE- LARGE LOCULATED RIGHT PLEURAL EFFUSION EXTENDING INTO THE MAJOR FISSURE.- A POCKET OF LOCULATED MEDIASTINAL PLEURAL EFFUSION ON RIGHT SIDE- CHRONIC CALCIFIC PANCREATITIS USG ABDOMEN 2/9/23 NO SONOLOGICAL ABNORMALITY DETECTED Treatment Given(Enter only Generic Name) 1.INJ.LEVIPIL 1GM IV/BD FOR 16 DAYS 2. INJ. NORAD AT 1.1 ML/HR FOR 7 DAY 3.INJ. DOBUTAMAMINE IV FOR 7 DAYS 4.INJ. VASOPRESSIN AT .5 ML/HR FOR 6 DAYS 5.FENTANYL+ MIDAZOLAM FOR 8 DAYS 6.INJ. HEPAIN FOR 13 DAYS 7.TAB. TOLVAPTAN FOR 6 DAYS 8.INJ. THIAMINE FOR 7 DAYS 9.INJ. HAI FOR 16 DAYS 10.INJ. PIPTAZ 2.25 GMS IV/TID FOR 5 DAYS 11.TAB.ATORVASTATIN+ ASPIRIN 75 MG RT/HS FOR 16 DAYS

12. TAB. OROFER XT RT/OD FOR 16 DAYS 13.NEBULIZATION WITH IPRAVENT 6TH HOURLY AND BUDECORT 4TH HOURLY FOR 16 DAYS 14.INJ.MEROPENEM 500MG IV/BD FOR 12 DAYS 15.TAB.FLUCONAZOLE 150MG RT/OD FOR 8 DAYS 16.INJ.VANCOMYCIN 500MG IV/BD FOR 5 DAYS 17.CHANGE OF POSITION 2 HRLY AND DAILY DRESSING OF BED SORE Follow Up DEATH SUMMARY A 55 YEAR OLD MALE WITH L5 (UNSTABLE) BURST FRACTURE (3 WEEKS) OLD AND WAS TRANSFERRED FROM ORTHOPEDICS TO GENERAL MEDICINE I/V/O HIGH GRBS. PATIENT SUGARS WERE CONTROLLED WITH INSULIN INFUSION AND HANDED OVER TO ORTHOPEDICS. AFTER 1 HR PATIENT DEVELOPED ALTERED SENSORIUM AND TRANSFERED TO GENERAL MEDICINE, ALTERED SENSORIUM MIGHT BE DUE TO ?HYPONATREMIA WHICH WAS CORRECTED WITH 3% NACL. NEXT DAY I/V/O FALLING SATURATION PATIENT WAS INTUBATED. HE ALSO HAD BRADYCARDIA AT THAT TIME FOR WHICH CPR WAS INITIATED,AND PATIENT REVIVED. AS THERE WERE DECREASED BREATH SOUNDS ON RIGHT SIDE OF CHEST, HRCT CHEST WAS DONE ON 31/8/23 ON WHICH PATIENT WAS FOUND TO HAVE RIGHT LOWER LOBE COLLAPSE WITH BRONCHIECTASIS, LARGE LOCULATED PLEURAL EFFUSION, EXTENDING INTO MAJOR FISSURE, POCKET OF LOCULATED MEDIASTINAL EFFUSION ON RIGHT SIDE WITH CHRONIC CALCIFIC PANCREATITIS. PATIENT DEVELOPED HEART FAILURE WITH EJECTION FRACTION 44% (INITIALLY 65%). DDIMER FOUND TO BE ELEVATED INITIALLY, PULMONARY EMBOLISM WAS SUSPECTED AND HEPARIN WAS ADDED TO THE TREATMENT. PATIENT HAD HYPOTENSION FOR WHICH HE WAS PLACED ON IONOTROPE SUPPORT. AS THERE WERE RAISED TLC AND FEVER SPIKES IN BETWEEN . PATIENT WAS STARTED ON ANTIBIOTICS. PATIENT HAS DECREASED URINE OUTPUT AND INCREASED SERUM UREA AND CRETININE. DIURETICS WERE ADDED TO THE TREATMENT AND GRADUALLY HIS URINE OUTPUT WAS INCREASED. HE WAS MAINTAINED ON VENTILATOR AND TRIPLE IONOTROPE SUPPORT. HIS BLOOD PRESSURE WAS GRADUALLY IMPROVED AND TRIPLE IONOTROPE SUPPORT WAS TAPERED GRADUALLY. PATIENT HAD RECURRENT EPISODES OF SEIZURES(DUE TO ?HYPOXIC ISCHEMIC ENCEPHALOPATHY) IN BETWEEN AND WAS CONTROLLED WITH ANTIEPILEPTICS. ON 6/9/23 PATIENT WAS TRACHEOSTOMISED AND MAITAINED ON VENTILATOR.

ON 12/9/23 PATIENT WAS CONNECTED TO T PIECE AND MAINTAINED ON OXYGEN. DUE TO LOW HB LEVELS 1PRBC TRANSFUSION WAS DONE ON 12/09/23. SEPSIS WAS RESOLVING GRADUALLY AND PATIENT WAS DE-ESCALATED FROM ANTIBIOTICS.GRADUALLY OXYGEN SUPPORT WAS TAPERED AND PATIENT WAS MAINTAINING ON ROOM AIR ON 14/09/23. ON 16/9/23 AT AROUND 2AMPATIENT WAS AGAIN CONNECTED TO OXYGEN SUPPORT I/V/O FALLING SATURATIONS AND MAINTAINED ON IT FOR ABOUT 2 HOURS AND AROUN 5 AM PATIENT HAD FALLING SATURATION EVEN WITH HIGH FLOW OXYGEN SUPPORT AND HAD BRADYCARDIA. AT AROUND 5 AM CPR WAS STARTED ACCORDING TO ACIS GUIDELINES AND CONTINUED FOR 30 MINS.INSPITE OF ALL THE ABOVE EFFORTS, PATIENT COULDN'T BE REVIVED AND DECLARED DEAD ON 16/09/23 AT 5:36 AMAND ECG SHOWED FLAT LINE. IMMEDIATED CAUSE OF DEATH: ACUTE DECOMPENSATED HEART FAILURE ANTECEDANT CAUSE OF DEATH: RIGHT LOWER LOBE COLLAPSE WITH BRONCHIECTASIS WITH RIGHT MIDDLE LOBE PLEURAL EFFUSION WITH SEPSIS ,SEPTIC ENCEPHALOPATHY WITH GRADE 2 BEDSORE WITH CHRONIC PANCREATITIS WITH CAD (S/P PTCA 2 YEARS AGO) K/C/O DM SINCE 20 YEARS.

PATIENT OUTCOME:

DIED IN HOSPITAL

Case 36:

71/M

Diagnosis Death Date: 25/09/2023 10:32 PM

UREMIC ENCEPHALOPATHY

DIABETIC NEPHROPATHY ON MHD (? CKD ON MHD) Case History and Clinical Findings C/O DECREASED URINE OUTPUT SINCE 4 MONTHS. HOPI- PATINT WAS APPARENTLY ASYMPTOMATIC 4 MONTHS BACK THEN DEVELOPED DECRESD URINE OUTPUT. PAST HISTORYPATIENT IS A K/C/O DM TYPE-2 SINCE 10YEARS AND IS ON MEDICATION. N/K/C/O HTN, TB , ASTHMA, EPILEPSY , CVA, CAD, THYROID DISORDERS. GENERAL AND PHYSICAL EXAMINATION: PATIENT IS CONSCIOUS ,COHERENT,COOPERATIVE NO SIGNS OF PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY EDEMA+ VITALS: TEMP-97.4 F PR-84 BPM RR-18 CPM BP-100/70 MMHG SPO2-99% ON ROOM AIR CVS-S1 S2 HEARD,NO MURMURS RS-BAE+,NVBS

Patient is in altered sensorium, irritable

CNS-NFND P/A- SOFT,NON TENDER,BOWEL SOUNDS HEARD Investigation CBP HB TC N L E M B PLT SMEAR RFT UR CR UA CA+2 P NA+ K+ CL- HIV HBSAG Name ValueNameValue BLOOD UREA12-09-2023 11:22:AM 107 mg/dl SERUM CREATININE12-09-2023 11:22:AM 6.9 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 12-09-2023 11:22:AM SODIUM 128 mEq/L POTASSIUM 3.4 mEq/L CHLORIDE 94 mEq/L CALCIUM IONIZED 1.27 mmol/LAnti HCV Antibodies - RAPID12-09-2023 11:22:AMNon Reactive HBsAg-RAPID12-09-2023 11:22:AM Negative COMPLETE BLOOD PICTURE (CBP) 12-09-2023 11:22:AM HAEMOGLOBIN 10.5 gm/dl TOTAL COUNT 18400 cells/cumm NEUTROPHILS 85 % LYMPHOCYTES 10 % EOSINOPHILS 01 % MONOCYTES

04 % BASOPHILS 00 % PLATELET COUNT 3.96 SMEAR Normocytic normochromic Anemia with neutrophilic leucocytosis ABG 19-09-2023 01:36:AM PH 7.29 PCO2 31.6 PO2 41.3HCO3 9.2 St.HCO3 9.2 BEB-2.1 BEecf-2.4 TCO2 44.8 O2 Sat 79.3 O2 Count 9.2 RFT 19-09-2023 01:36:AM UREA 78 mg/dl CREATININE 5.3 mg/dl URIC ACID

Treatment Given(Enter only Generic Name) 1. FLUID RESTRICTION <15L/DAY 2. SALT RESTRICTION <2GM/DAY 3.INJ. NARADRENALINE (4ML+40ML NS) 4. INJ. DOBUTAMINE (5ML +45ML NS) 5.INJ. VASOPRESSIN (1ML + 39ML NS) 6. INJ. MIDAZOLAM 30 ML +INJ FENTANYL 4ML +16ML NS INFUSION @ 4ML +16 ML NS 7. IV. FLUIDS NS @30ML /HR 8. INJ. LASIX 20 MG IV BD 9. INJ. NEOMOL 1GM IV IF TEMP >101 F 10. INJ. HUMAN ACTRAPID INSULIN ACC TO GRBS 11. 7 PROFILE GRBS MONITORING 12 RT FEEDS- WATER HOURLY, MILK 2ND HOURLY 13. TAB. DOLO 650 MG RT/ BD SOS 14. TAB. LINEZOLID 600MG RT/ BD 15. MONITOR VITALS HOURLY 16. INJ . MEROPENEM 500MG /IV/ BD.

Death Summary A 71 YEAR OLD MALE PRESENTED WITH NON- HEALING ULCER OVER RIGHT LOWER LIMB TO CASULTY AND I/V/O RAISED RENAL PARAMETERS. DIALYSIS WAS INITIATED WITH DIAGNOSIS AKISECONDARY TO RIGHT LOWER LIMB CELLULITIS. SURGERY OPINION WAS TAKEN I/V/O CELLULITIS FOR WHICH DEBRIDEMENT WAS DONE INITIALLY AFTER 2 SESSIONS OF DIALYSIS . AND ON FURTHER EVALUATION BELOW KNEE AMPUTATION WAS PLANNED DUE TO ECTREME DESTRUCTION OF UNDERLYING TISSUE.AFTER 4 SESSIONS OF DIALYSIS RENAL PARAMETERS UREA AND CREATININE WERE REDUCED AND SURGERY WAS PLANNED FOR BELOW KNEE AMPUTATION AFTER GIVING HIGH RISK BY NEPHROLOGIST. AFTER SURGRY THERE WAS SUDDEN DECRESE IN URINARY OUTPUT (WHICH WAS NORMALPREVIOUSLY )AND FURTHER DIALYSIS WAS DONE . PATIENTS SENSORIUN DETERORATED GRADUALLY I/V/O FALL IN SATURATIONS AND HEARTRATE PATIENT WAS INTUBATED . DURING INTUBATION PATIENT HAD SUDDEN CARDIAC ARREST AND CPR WAS DONE ACCORDING TO LATEST ACCS GUIDELINES FOR A PERIOD OF 20MINS AND ROSC ACHIVED AND PATIENT PUT ON MECHANICALVENTILATOR IN ACMN -VE MODE. FURTHER GENERALSURGERY OPINION WAS TAKEN AND PLANNED FOR FURTHER DEBRIDEMENT OF WOUND BUT I/V/O PATIENTS PRESENT CONDITION IT WAS NOT DONE. PATIENT ALSO DEVELOPED HYPOTENSION SECONDARY TO SEPSIS AND WAS PUT ON IONOTROPIC SUPPORT AND 2 INJ. NORADRENALINE AND 2INJ. DOBUTAMIN AND 2INJ . VASOPRESSINE WITH ALL IONOTROPIC SUPPORT PATIENT WAS TAKEN UP FOR 1 SESSION DIALYSIS ALONG WITHBLOOD TRANSFUSION. PATIENT WAS HAVING PERSISTENT HYPOTENSION EVEN WITH IONOTROPIC SUPPORT AND ON 25/9/23 AT11 PM THERE WAS SUDDEN DROP IN SATURATIONS AND WITH PULSE AND BP NOT RECORDABLE, IMMEDIATELY CPR WAS INITIATED ACC TO LATEST AHA GUIDLINES BUT INSPITITE OF ALL RESUSCITATIVE EFFORTS PATIENT COULDN'T BE REVIVED AND DECLARED DEAD OM 25/9/23 AT 11:32PM IMMDEDIATED CAUSE OF DEATH - REFRACTORY HYPOTENSION WITH TYPE -1 RESPIRATORY FAILURE.

ANTECEDENTCAUSE- UREMIC ENCEPHALOPATHY CHRONIC KIDNEY DISEASE WITH S/P RIGHT BELOW KNEE AMPUTATION SECONDARY TO RIGHT LOWER LIMB CELLULITIS WITH K/C/O DM TYPE-2

PATIENT OUTCOME: DIED IN HOSPITAL

Case 37:

56/M

Diagnosis UREMIC ENCEPHALOPATHY

AKI ON CKD?NSAID ABUSE Case History and Clinical Findings C/O FEVER SINCE 10 DAYS HEADACHE WITH GIDDINESS SINCE 10 DAYS

ALTERED SENSORIUM SINCE 1 DAY

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK,THEN DEVELOPED FEVER,HIGH GRADE,ASSOCIATED WITH CHIILS,INSIDIOUS IN ONSET,GRADUALLY PROGRESSIVE,ASSOCIATED WITH HEADACHE,GIDDINESS SINCE 10 DAYS. C/O HEADACHE DECREASED SINCE 2 DAYS H/O BURNING MICTURITION H/O DECREASED URINE OUTPUT PRESENT AND ALTERED SENSORIUM SINCE 1 DAY.H/O PEDAL EDEMA O AND OFF SINCE 10 DAYS,SINCE 6-7 MONTHS NO H/O COUGH COLD NO H/O CKD N/K/C/O HTN,DM,CAD,CVA,THYROID DISORDER,EPILEPSY Investigation HEMOGRAM HB-6.3GM/DL TC-19500 N-86 L-10

E-2 M-2 B-00 SMEAR-NORMOCYTIC NORMOCHROMIC HIV-NEGATIVE HBSAG-NEGATIVE HCV-NEGATIVE Treatment Given(Enter only Generic Name) 1) IVF 1 NS@75ML/HR 2) INJ.LASIX 20MG IV BD 3) INJ.NODOSIS 500MG PO/BD 4) INJ.NEOMOL 1G IV 5) MONITOR VITALS 4TH HRLY 6) INFORM SOS Advice at Discharge LAMA NOTES PATIENT ATTENDERS HAVE BEEN EXPLAINED IN THEIR OWN UNDERSTANDABLE LANGUAGE ABOUT THE CONDITION ASSOCIATED WITH THE CONDITION OF DERANGED RENAL PARAMETERS OF SR.UREA 210 AND SR.CREATININE 7.2 . A 62 YEAR OLD MALE PATIENT BROUGHT TO CASUALITY CC/O FEVER ON AND OFF SINCE 10 DAYS.DECREASED URINE OUTPUT SINCE 5 DAYS.BILATERAL PEDAL EDEMA SINCE 10 DAYS BACK SUBSIDED AFTER TAKING OUTSIDE TREATMENT.DESPITE OF EXPLAINING ABOUT THE CONDITION AND RISK ASSOCIATED WITH CONDITION AND NEED FOR HEMODIALYSIS AND HOSPITAL STAY FOR FURTHER MANAGEMENT.PATIENT LEFT AGAINST MEDICAL ADVICE..

PATIENT OUTCOME:

GOOD RECOVERY ON FOLLOW UP

Case 38:

70,F

Diagnosis:

HEPATIC ENCEPHALOPATHY

HYPERTONIC HYPERNATREMIA SECONDARY TO DEHYDRATION (RESOLVED) Case History and Clinical Findings PATIENT WAS BOUGHT TO CASUALITY WITH GENERALISED WEAKNESS SINCE 3 DAYS HOPI: PATIENT WAS APPARENTLY ALRIGHT 3 DAYS BACK TODAY PATIENT ATTENDER SAW HER ON THE FLOOR WITH HER CLOTHES STAINED WITH FAECES AND MICTURTION NO FOOD INTAKE SINCE LAST 3 DAYS

Altered sensorium since today morning

NO C/O CHEST PAIN , FEVER , SOB , PALPITATIONS NO VOMITINGS , LOOSE STOOLS SHE IS ABLE TO LIFT HER HANDS AND LEGS PAST HISTORY : N/K/C/O HTN , DM 2 , THYROID DISORDERS , CVA , CAD PERSONAL HISTORY: MIXED DIET APPETITE LOST BOWEL AND BLADDER - REGULAR ADDICTION : REGULAR 180 ML DAILY ALCOHOL CONSUMPTION SINCE 10 YEARS GENERAL EXAMINATION: PATIENT IS CONSCIOUS,NON COHERENT,NON COOPERATIVE

ICTERUS PRESENT ,PEDAL EDEMA PRESENT

NO SIGNS OF PALLOR,CLUBBING,CYANOSIS ,LYMPHADENOPATHY.VITALSTEMP- 99.9 F PR- 124 BP RR-22 CPM BP-120/70MMHG SPO2- 99% AT RA CVS- S1,S2 HEARD , NO MURMERS RS- BLAE PRESENT , NO ADDED SOUNDS P/A- SOFT, NON TENDER NO ORGANOMEGALY CNS- RIGHT LEFT TONE : UL N N LL N N POWER : UL 4/5 4/5 LL 4/5 4/5 REFLEXES BICEPS + 2 +2 TRICEPS +2 +2 SUPINATOR +1 +1 KNEE +2 +2 ANKLE +1 +1 PLANTAR F F Investigation 2D ECHO DONE ON 3/10/23 : TACHYCARDIA NO RWMA MILD LVH + [ 1.23 CMS] MILD TR + WITH PAH[ 33+10 = 43 MMHG ] MODERATE AR + , TRIVIAL MR + SCLEROTIC AV , THICKENED AV IAS - INTACT EF = 57 % GOOD LV SYSTOLC FUNCTION DIASTOLIC DYSFUNCTION + , NO AS/MS MINIMAL PE + IVC SIZE [0.7CMS] COLLAPSNG USG DONE ON 2/10/23

IMPRESSION : COARSE ECHO TEXTURE OF LIVER FATTY LIVER Treatment Given(Enter only Generic Name) 1.IVF NS , RL @ 100ML/HR 2.INJ OPTINEURON 1 AMP IN 100 ML NS IV /OD 3.INJ THIAMINE 100 MG IV /BD 4.TAB UDILIV 300 MG PO/BD 5.SYP LACTULOSE 15 ML PO / BD Advice at Discharge 1.TAB.BENFOMET 100MG PO/OD X 1 WEEK 2.TAB UDILIV 300MG PO/BD X 1 WEEK 3.SYP.LACTULOSE 15ML PO/HS 4.PLENTY OF ORAL FLUIDS

Patient outcome:

GOOD RECOVERY

Case 39:

47/M

Diagnosis ALTERED SENSORIUM SECONDARY TO UREMIC ENCEPHALOPATHY WITH RENAL AKI ON CKD( RESOLVING) STAGE V(RESOLVED) SECONDARY TO DIABETIC NEPHROPATHY WITH PYREXIA UNDER EVALUATION SECONDARY TO ?URTI , DM SINCE 7 YRS, DE NOVO HTN Case History and Clinical Findings PT WAS BROUGHT TO HOSPITAL WITH C/O FEVER SINCE 15 DAYS, GENERALIZED WEAKNESS SINCE 10 DAYS, BURNING MICTURITION SINCE 10 DAYS, COUGH SINCE 10 DAYS, MULTIPLE JOINT PAINS SINCE 1 WEEK OCCASIONAL IRRITABILITY PRESENT , FLUCTUATING SENSORIUM SINCE 10 DAYS HOPI - PT WAS APPARENTLY ASYMPTOMATIC 15 DAYS BACK THEN HE DEVELOPED FEVER WHICH IS HIGH GRADE, ASSOCIATED WITH CHILLS AND RIGORS, CONTINUOUS, RELIEVED WITH MEDICATION, NO DIURNAL VARIATION GENERALISED WEAKNESS SINCE 10 DAYS BURNING MICTURITION SINCE 10 DAYS COUGH SINCE 10 DAYS, PRODUCTIVE COUGH, SCANTY, NON-FOUL SMELLING, NOT BLOOD STAINED MULTIPLE JOINT PAINS SINCE 1 WEEK, OCCASIONAL IRRITABILITY + FLUCTUATING SENSORIUM SINCE 10 DAYS , NOT ABLE TO IDENTIFY ATTENDERS SOMETIMES, IRRELEVANT TALK PRESENT H/O VOMITINGS SINCE 1 WEEK, NON-BILIOUS, NON PROJECTILE, NON BLOOD TINGED H/O HYPOGLYCEMIC EPISODES PRESENT, 3 EPISODES 3 MONTHS AGO

PAST HISTORY - K/C/O TYPE 2 DM SINCE 7 YRS ON UNKNOWN MEDICATION, STOPPED MEDICATION SINCE 3 MONTHS N/K/C/O HTN, TB, ASTHMA, CAD, CVA, EPILEPSY PERSONAL HISTORY DIET - MIXED APPETITE - NORMAL SLEEP - ADEQUATE BOWEL - REGULAR ADDICTIONS - CONSUMED ALCOHOL REGULARLY DAILY 2-3 QUARTERS STOPPED 4 MOTNHS AGO TOBACCO SNUFF SINCE 30 YRS ABOUT 10-12 CIGARETTES PER DAY BETEL LEAF CONSUMPTION SINCE 20 YRS GENERAL PHYSICAL EXAMINATION PATIENT IS CONCIOUS, COHERENT, COOPERATIVE VITALS PR - 98 BPM BP -160/100 MM HG RR - 18 CPM TEMP - AFEBRILE GRBS - 105 MG/DL SPO2 - 98 @ RA SYSTEMIC EXAMINATION CVS : S1 S2 + RS : BAE +, TRACHEA CENTRAL , NVBS HEARD P/A :SOFT , NON TENDER CNS - NFND OPTHALMOLOGY REFERRAL DONE ON 20/10/23 I/V/O DIABETIC RETINOPATHY AND RAISED ICP FEATURES IMPRESSION - HYPERTENSIVE RETINOPATHY CHANGES NOTED GRADE 3 IN BOTH EYES, NO SIGNS OF DM RETINOPATHY NOTED AND RAISED ICT AS OF NOW ADVICE - STRICT BP CONTROL REVIEW OPHTAL OPD FOR V/A &AR/REF UROLOGY REFERRAL DONE I/V/O AV FISTULA ON 24/10/23 ADVICE - USG LT UPPER LIMB ARTERIAL + VENOUS

AVOID LT UL IV CANNULATION STRESS BALL PHYSIOTHERAPY x 1 WEEK Investigation HBsAg-RAPID19-10-2023 04:39:PM Negative Anti HCV Antibodies - RAPID19-10-2023 04:39:PM Non Reactive COMPLETE URINE EXAMINATION (CUE) 19-10-2023 04:39:PM 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 Page-3 AMORPHOUS DEPOSITS

Absent OTHERS Nil BLOOD UREA19-10-2023 04:39:PM 229 mg/dl SERUM CREATININE19-10-2023 04:39:PM 12.7 mg/dl SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 19-10-2023 04:39:PM SODIUM 134 mEq/L POTASSIUM 5.8 mEq/L CHLORIDE 105 mEq/L CALCIUM IONIZED 1.19 mmol/L LIVER FUNCTION TEST (LFT) 19-10-2023 04:39:PM Total Bilurubin 0.70 mg/dl Direct Bilurubin 0.18 mg/dl SGOT(AST) 17 IU/L SGPT(ALT) 14 IU/L ALKALINE PHOSPHATE 297 IU/L TOTAL PROTEINS 6.5 gm/dl ALBUMIN 3.7 gm/dl A/G RATIO 1.30 BLOOD UREA19-10-2023 10:45:PM 226 mg/dl

2D ECHO DONE ON 19/10/23 EF - 65 % MILD AR+, MILD TR+ WITH PAH, TRIVIAL MR+ NO RWMA, NO AS/MS, SCLEROTIC AV GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION + , NO PE USG DONE ON 19/10/23 FINDINGS - E/O 12X7 MM EXOPHYTIC CYST IN RT KIDNEY MIDPOLE &8X8 MM EXOPHYTIC CYST IN LEFT KIDNEY

E/O FEW TINY CALCULI NOTED IN THE LEFT KIDNEY LARGEST MEASURING 3MM MIDPOLE IMPRESSION - RAISED ECHOGENECITY OF RIGHT KIDNEY CORRELATE WITH RFT, B/L SIMPLE RENAL CORTICAL CYSTS, LEFT RENAL CALCULI, GRADE 1 FATTY LIVER Treatment Given(Enter only Generic Name) INJ PIPTAZ 2.25 G IV/TID INJ PAN 40 MG IV / OD INJ LASIX 40MG IV/BD TAB NICARDIA 20MG PO/BD TAB SHELCAL CT 500 MG PO/OD TAB OROFER XT PO/OD TAB LIMCEE PO/OD TAB NODOSIS 1G PO/BD INJ EPO 4000 IU SC ONCE WEEKLY INJ SUCROSE 200MG IN 100 ML NS IV/ OD INJ HAI SC/TID ACCORDING TO GRBSINJ PIPTAZ 2.25 G IV/TID Advice at Discharge TAB PAN 40 MG PO / OD TAB LASIX 40MG PO/BD TAB NICARDIA 20MG PO/BD TAB SHELCAL CT 500 MG PO/OD TAB OROFER XT PO/OD TAB LIMCEE PO/OD TAB NODOSIS 1G PO/BD INJ EPO 4000 IU SC ONCE WEEKLY INJ HAI SC/TID 8AM-1PM-8PM 4U-4U-4U

Patient outcome:

GOOD RECOVERY

Case 40:

50/M

Diagnosis Death Date: 25/10/2023 07:21 AM ALTERED SENSORIUM SECONDARY TO ? UREMIC ENCEPHALOPATHY / ? SEPTIC ENCEPHALOPATHY AKI ON CKD SEPTIC SHOCK WITH MODS SECONDARY TO ? RIGHT UPPER LIMB CELLULITIS ? LYMPHEDEMA WITH SEVERE METABOLIC ACIDOSIS WITH DM TYPE 2 Case History and Clinical Findings CHIEF COMPLAINTS: PATIENT C/O RIGHT SHOULDER PAIN AND RIGHT UPPER LIMB SWELLING SINCE 15 DAYS C/O GENERALIZED WEAKNESS SINCE 10 DAYS C/O GENERALIZED SWELLING OF THE BODY SINCE 3 DAYS C/O SHORTNESS OF BREATH SINCE 3 DAYS C/O DECREASED URINE OUTPUT SINCE 2 DAYS C/O ALTERED SENSORIUM SINCE 1 DAY

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 2 WEEKS AGO THEN HE DEVELOPED TRAUMA TO THE RIGHT HAND ( WHILE OPENING SHUTTER) AND HAD INJURY TO THE SHOULDER. SLOWLY HE DEVELOPED SWELLING OF THE RIGHT UPPER LIMB GIDDINESS SINCE 1 WEEK. GENERALIZED SWELLING OF THE BODY SINCE 3 DAYS ALTERED SENSORIUM SINCE 1 DAY. H/O UNCONTROLLED SUGARS 4 DAYS BACK. DECREASED URINE OUTPUT SINCE 3 DAYS SHORTNESS OF BREATH SINCE 3 DAYS, INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE, GREDE 2 TO 4. ORTHOPNEA PRESENT. PAST ILLNESS: K/C/O DM TYPE 2 SINCE 18 YEARS ON IRREGULAR MEDICATION. H/O ADMISSION FOR ? CHRONIC LIVER DISEASE 15 YRS AGO ON EXAMINATION : PATIENT IS DROWSY,BUT AROUSABLE VITALS TEMP-AFEBRILE PR-96/MIN BP-80/60 MM HG RR-30/MIN SPO2-90 ON RA DEATH SUMMARY :

50 YEAR OLD MALE DAILY WAGE LABOURER K/C/O TYPE 2 DM SINCE 18 YEARS PRESENTED WITH COMPLAINTS OF RIGHT SHOULDER PAIN AND SWELLING SINCE 15 DAYS , GENERALISED WEAKNESS SINCE 10 DAYS , SHORTNESS OF BREATH SINCE 3 DAYS , ALTERED SENSORIUM SINCE 2 DAYS , DECREASED URINE OUTPUT SINCE 3 DAYS VITALS AT THE TIME OF ADMISSION BP 70/40 MM HG, PR 98/ MIN, SPO2 90 % ON RA, 96 % ON 5 L O2, TEMP 98.8 DEGREE F. PATIENT WAS PROVISIONALLY DIAGNOSED AS ALTERED SENSORIUM SECONDARY TO ?UREMIC ENCEPHALOPATHY ?SEPTIC ENCEPHALOPATHY WITH SEPTIC SHOCK WITH SEVERE METABOLIC ACIDOSIS WITH RIGHT UPPER LIMB LYMPHEDEMA/ CELLULITIS WITH BURSITIS. PATIENT WAS STARTED ON IV FLUIDS, ADEQUATE FLUID RESUSCITATION WAS DON. INJ NORAD INFUSION WAS STARTED. INJ SODIUM BICARBONATE 50 MeQ SLOW IV FOLLOWED BY INJ SODA BICARBONATE 100 MeQ IN 100ML NS. INVESTIGATIONS REVEALED HB:9.8 GM/DL, TLC - 5400/CUMM, N/L/E/M/B: 92/3/0/5/0, PCV: 28.3, PLATELETS: 2.7 X 10*5/CUMM, CREATININE: 40 mg/dl, BLOOD UREA: 213 mg/dl, SERUM SODIUM:124 MEQ/L, SERUM POTASSIUM: 5.4 MEQ/L, CHLORIDE: 95 MEQ/L, ABG PH- 7.14, PCO2- 17.9 PO2- 85.1 HCO3- 5.9 02 SATURATION- 92.5. AT 9PM. DURING DIALYSIS PATIENT HAS FALLING BLOOD PRESSURE. INJ DOBUTAMINE AND VASOPRESSIN WAS STARTED. 1 HOUR IN VIEW OF DERANGED RFT PATIENT ATTENDER HAVE BEEN EXPLAINED ABOUT THE NEED FOR CENTRAL LINE AND HO. AFTER TAKING CONSENT FROM PATIENT ATTENDERS RIGHT FEMORAL CENTRAL LINE WAS PLACED. PATIENT WAS TAKEN UP FOR DIALYSIS AFTER DIALYSIS PATIENT HAS SUDDEN FALL OF SATURATION AND UNRESPONSIVE CRASH INTUBATION WAS DONE WITH 7.0 MMET TUBE AND WAS CONNECTED TO ACMV-VC MODE. IN VIEW OF SEVERE SEPSIS PATIENT WAS STARTED ON INJ MEROPENAM AND PIPTAZ. AT AROUND 6:40 AM PATIENT HAD SUDDEN BRADYCARDIA AMD DESATURATION. IMMEDIATE CPR WAS STARTED AS PER THE LATEST ACLS GUIDELINE AND CONTINUED FOR 30 MINUTES. DESPITE THE ABOVE RESUSCITATION EFFORTS THE PATIENT CANNOT BE REVIVED AND DECLARED DEAD AT 7:12 AM AFTER THE ECG SHOWED FLAT LINE. IMMEDIATE CAUSE OF DEATH: 1. SEVERE METABOLIC ACIDOSIS 2. SEPTIC SHOCK WITH REFRACTORY HYPOTENSION 3. ALTERED SENSORIUM SECONDARY TO ?UREMIC ENCEPHALOPATHY ?SEPTIC ENCEPHALOPATHY. ANTECEDENT CAUSE OF DEATH: 1. PRE RENAL AKI ON CKD 2. RIGHT UPPER LIMB LYMPHEDEMA/ CELLULITIS 3. TYPE 2 DM

Investigation HEMOGRAM HB 9.8 GM /DL TLC 54,000 CELLS/CUMM N/L/E/M/B 92/3/0/5/0 PCV 28.3 PLT 2.7 LAKHS/CUMM RFT BLOOD UREA 213 MG/DL SERUM CREATININE 40 MG/DL SERUM SODIUM 124 MEQ/L /DL SEUM POTASSIUM 5.4 MEQ/L SERUM CL 95 MEQ/L FBS 87 MG/DL CUE ALBUMIN 1+ SUGARS NIL PUS CELLS 4-6 /HPF EPITHELIAL CELLS 3-4 /HPF RBC S 6-8 CELLS /HPF LFT TB 3.07 MG/DL DIRECT BILIRUBIN 2.72 MG/DL SGOT 63 IU/L SGPT 27 IU/L ALP 218 IU/L TOTAL PROTEIN 5.5 GM/DL ALBUMIN 2.12 GM/DL A/G RATIO 0.6 ABG PH 7.14 PCO2 17.9 MM HG PO2 85.1 MMHG

HCO3 5.9 MMOL/L RIGHT UPPER LIMB ARTERIAL DOPPLER DONE ON 24/10/23 IMPRESSION: DECREASED FLOW IN RADIAL AND ULNAR ARTERIES DIFFUSE SUBCUTANEOUS EDEMA FROM SHOULDER TO HAND USG ABDOMEN AND PELVIS ON 24/10/23 RT KIDNEY :10.4X5.1CMS LT KIDNEY: 10.2X4.8CMS IMPRESSION: MILD HEPATOSPLEENOMEGALY HYPERECHOIC FOCI IN GALLBLADDER GALLBLADDER POLY(N) CALCULI Treatment Given(Enter only Generic Name) 1.IV FLUIDS NS @UO+30ML/HR 2.INJ.SODIUM BICARBONATE 50MEQ SLOW IV OVER 1 NS 3.INJ.SODIUM BICARBONATE 50MEQ 100ML NS OVER 1HR 4.NEBULIZATION WITH DUOLIN AND BUDECORTP/N STAT 5.INJ. NORAD 4ML IN 46ML NS (INCREASE OR DECREASE AS PER MAP >65MMHG) 6.INJ.PIPTAZ 4.5GM IV/STAT FOLLOWED BY INJ.PIPTAZ 2.25GM IV/TID 7.INJ.CLINDAMYCIN 600MG IV/BD 8. INJ. MEROPENEM 1 GM IV STAT F/B 500MG IV BD 8.INJ. PAN 40MG IV/OD 9. INJ DOBUTAMINE 1 AMP IN 45 ML NS @ 4ML/HR TO INCREASE OR DECREASE AS PER MAP GREATER THAN 65 MMHG. 10. INJ VASOPRESSIN 1 AMP IN 39 ML NS @ 2.4 ML/HR TO INCREASE OR DECREASE TO MAINTAIN MAP GREATER THAN 65MMHG.

Patient outcome:

patient DIED IN HOSPITAL

Case 41:

43/F

Diagnosis Death Date: 03/07/2022 01:07 AM

UREMIC ENCEPHALOPATHY

CKD ON MHD WITH ACUTE PULMONARY EDEMA WITH GROSS ASCITIS Case History and Clinical Findings PATIENT WAS APPARENTLY ASYMPTOMRTIC 2YEAT AGO DEVELOPED PEDEMA AND SOB , URINE OUT PUT DECREASED SINCE 2 YEARS CKD ON MHD , DIALSIS START 2YEARS K/C/O HTN CINCE 2 YEARS

SUDDEN ONSET SOB SINCE TODAY EVENING AND ALTERED SENSORIUM SINCE TODAY EVENING

K/C/O NO . TB , DM , BP 140/90/MMHG PULSE 92/MT TEMT 98.6 F DEATH SUMMARY

A 42 YEAR OLD FEMALE CAME WITH COMPLAINTS OF ABDOMINAL SWELLING AND PEDAL EDEMA SINCE 10DAYSS,AND SHORTNESS OF BREATH AT REST SINCE TODAY EVENING AND ALTERED SENSORIUM SINCE TODAY EVENING AND SHE IS A K/C/O CKD AND ON MHD AND PATIENT IS ON NIV AND AROUND 7 PM PATIENT COMPLAINED OF INCREASED SOB AND DEVELOPED ACUTE PULMONARY EDEMA AND PATIENT SHIFTED TO DIALYSIS AND AT THAT TIME PATIENT VITALS ARE STABLE AND AND BILATERAL DIFFUSE CREPTS ARE HEARD AND AFTER SHIFTING TO DIALYSIS PATIENT AV FISTULA IS NOT WORKING AND PATIENT ATTENDERS COUNSELLED FOR CENTRAL LINE FOR WHICH THEY DENIED.AND THEN DUE TO UNRESPONSIVENESS OF PATIENT AND SPO2 WAS AROUND 52% ON ROOM AIR AND NO PERIPHERAL PULSES WERE FELT AND EMERGENCY INTUBATION WAS DONE WITH ET7 AND MECHANICAL VENTILATOR IN ACMV -VC MODE AND VT 450ML AND PEEP 5CM OF H2O AND RR 14CPM AND POST INTUBATION SBP WAS AROUND 50MMHG ON PALPTORY METHOD AND DIFFUSE CREPTS WERE FOUND AND PATIENT SHIFTED TO ICU AND HER GCS E2VTM4 AND AROUND 12:00AM PATIENT WENT TO BRADYCARDIA AND UNRESPONSIVE AND PERIPHERAL PULSES WERE NOT FELT AND THEN CPR WAS STARTED ACCORDING TO ACLS 2020 GUIDELINES AND CPR WAS DONE FOR 30MINUTES . INSPITE OF ALL RESCUCITATIVE EFFORTS PATIENT COULDNOT BE REVIVED AND DECLARED DEAD ON 0N 3-07-2022 AT 1;07AM IMMEDIATE CAUSE OF DEATH- ACUTE ON CHRONIC LVF,ACUTE PULMONARY EDEMA ,SEPSIS WITH REFRACTORY HYPOTENSION ANTECEDENT CAUSE OF DEATH CKD ON MHD ,HFrEF ,GROSS ASCITIS ? TB /? MALIGNANCY Investigation CBP HB TC N L E M B PLT SMEAR RFT UR CR UA CA+2 P NA+ K+ CL- HIV HBSAG HCV Treatment Given(Enter only Generic Name) TAB .SHELCAL 500MG OD TAB . NODOSIS 500MG BD TAB . PAN 40 MG OD TAB . OROFER XT OD TAB BIO D3 OD TAB . NICARDIA 20MG BD TAB ARKAMINE BD Death Date Date: 3-07 -2022

PATIENT OUTCOME: PATIENT DIED IN HOSPITAL.

Case 42:

47/M

Diagnosis

UREMIC ENCEPHALOPATHY

CKD ON MHD

Case History and Clinical Findings C/O ALTERED SENSORIUM SINCE 1 DAY

HOPI : PATIENT WAS APPARENTLY ASYMPTOMATIC 20 DAYS BACK THEN HE DEVELOPED ANASARCA AND WENT TO LOCAL HOSPITAL WHERE IT WAS DIAGNOSED AS CKD UNDERWENT 6 SESSIONS OF DIALYSIS IN THE LAST DIALYSIS PAT WAS UNABLE TO LIFT HIS LEG ON WALKING SINCE 1 DAY . PATIENT WAS IRRELAVENT TO WALK PAST HISTORY ; K/C/O DM 2 SINCE 10YEARS ON MEDI K/C/O HTN SINCE 20DAYS AND ON NICARDIA 20 MG N/K/C/O ASTHMA , EPILEPSY , TB , CAD , THYROID DISORDERS PERSONAL HISTORY : DIET :MIXED APPETITE : GOOD SLEEP : ADEQUATE BOWEL: REGULAR BLADDER HABITS : REGULAR GENERAL EXAMINATION : PATIENT IS CONSCIOUS , COHERENT , COOPERATIVE

PALOR + PEDAL EDEMA + NO SIGNS OF CLUBBING , ICTERUS , CYANOSIS , LYMPHEDNOPATHY VITALS : TEMP : 96.8 F PR : 100 BPM BP : 160/90 MMHG GRBS : 124 MG / DL SPO2 : 98 % RR : 28 CPM SYSTEMIC EXAMINATION : CVS : S1 , S2 HEARD , NO MURMURS RS : BAE + , NVBSHEARD PA : SOFT , NON TENDER , BS + CNS : NFAD Investigation Anti HCV Antibodies - RAPID06-10-2023 09:07:AM Non Reactive HBsAg-RAPID06-10-2023 09:07:AMNegative COMPLETE URINE EXAMINATION (CUE) 06-10-2023 09:07:AM COLOUR Milky white APPEARANCE Cloudy REACTION Acidic SP.GRAVITY 1.010 ALBUMIN ++ SUGAR Nil BILE SALTS Nil BILE PIGMENTS

Nil PUS CELLS plenty EPITHELIAL CELLS 1-2 RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil LIVER FUNCTION TEST (LFT) 06-10-2023 09:07:AM Total Bilurubin 0.53 mg/dl Direct Bilurubin 0.16 mg/dl SGOT(AST) 25 IU/L SGPT(ALT) 19 IU/L ALKALINE PHOSPHATE 204 IU/L TOTAL PROTEINS 6.0 gm/dl ALBUMIN 2.6 gm/dl A/G RATIO 0.74 Page-3 RFT 06-10-2023 09:07:AM UREA

58 mg/dl CREATININE 4.9 mg/dl URIC ACID 3.4 mg/dl CALCIUM 9.5 mg/dl PHOSPHOROUS 3.2 mg/dl SODIUM 132 mEq/L POTASSIUM 3.9 mEq/L CHLORIDE99 mEq/LRFT 31-10-2023 07:45:PM UREA 104 mg/dl CREATININE 7.4 mg/dl URIC ACID 4.9 mg/dl CALCIUM 8.0 mg/dl PHOSPHOROUS 2.4 mg/dl SODIUM 129 mEq/L POTASSIUM 4.1 mEq/L CHLORIDE 98 mEq/L RFT 01-11-2023 06:30:AM UREA 95 mg/dl CREATININE 6.7 mg/dl URIC ACID

Treatment Given(Enter only Generic Name) FLUID RESTRICTION <1LITER/DAY SALT RESTRICTION <1GM/DAY TAB NICARDIA 20MG PO/OD TAB OROFER XT PO/OD INJ EPO 4K S/C TWICE WEEK INJ IRON SUCROSE IN 100ML NS IV TWICE WEEKLY When to Obtain Urgent Care IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

Patient outcome:GOOD RECOVERY WITH DIALYSIS

Case 43:

60/F

Diagnosis SEPTIC ENCEPHALOPATHY

HISTORY OF PRESENT ILLNESS:PATIENT WAS APPARENTLY NORMAL 1 DAY BACK THEN DEVELOPED PAIN ABDOMEN DRAGGING TYPE NON RADIATING LOCALISED TO UMBILICAL REGION ASSOCIATED WITH 2 EPISODES OF VOMITINGS WATERY NON BILIOUS NON PRTOJECTILE WITH FOOD PARTICLES AS CONTENTS C/O DECREASED URINE OUTPUT SINCE LAST NIGHT H/O FEVER 3 DAYS BACK HIGH GRADE INTERMITTENT ASSOCIATED WITH CHILLS AND RIGORS RELIEVED BY MEDICATION C/O PAIN IN LEFT LOWER LIMB, SWELLING PRESENT, PITTING TYPE, EXTENDING UPTO THE KNEE, TENDERNESS PRESENT C/O SHORTNESS OF BREATH SINCE LAST NIGHT AND IRRELEVANT TALK SINCE MORNING NO C/O CHESTPAIN,PALPITATIONS, ORTHOPNEA, PND, LOOSE STOOLS AND FACIAL PUFFINESS PAST HISTORY:PATIENT IS A K/C/O HYPERTENSION SINCE 5 YEARS USING TAB.ATENOLOL 50MG OD

Patient outcome:

Patient went on LAMA, Died after 5 days(ok followup).Case 44:

50/M

Diagnosis AKI SECONDARY LOWER RESPIRATORY TRACT INFECTION ON CKD ( STAGE V ) ALTERED SENSORIUM SECONDARY TO TRUE HYPONATREMIA -? DILUTIONAL WITH ANEMIA-MIHC K/C/O HTN WITH HYPERTENSION WITH RETINOPATHY Case History and Clinical Findings C/O COUGH SINCE 20 DYAS,FEVER SINCE 1 WEEK SHORTNESS OF BREATH SINCE 5 DAYS BILATERAL PEDL EDEMA SINCE 30 DAYS DECERASED URINE OUTPUT SINCE 1 DAY ALTERED SENSORIUM SINCE 8 HRS AND ALTERED SENSORIUM SINCE 6HOURS.

PATIENT WAS APPARENTLY ASYMPTOMATIC 20 DAYS AGO THEN HE DEVELOPED COUGH SINCE 20 DAYS,PRODUCTIVE TYPE WITH YELLOWISH WHITE COLOURED SPUTUM,SCANTY IN NATURE,NOT BLOOD TINGED AND FOUL SMELLING FEVER SINCE 1 WEEK,LOW GRADE,NOTT ASSOCIATED WITH CHILLS AND RIGORS SHORTNESS OF BREATH SINCE 5 DAYS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE PROGRESSED FROM GRADE 2 TO GRADE 4.AND ALTERED SENSORIUM SINCE 6 HOURS.

ORTHOPNEA PRESENT NO PND. BILATERAL PEDAL EDEMA SINCE 3 DAYS,DECREASED URINE OUTPUT ,N/H/O VOMITINGS,LOOSE STOOLS,PAIN ABDOMEN

K/C/O HTN SINCE 3 YEARS NOT ON REGULAR MEDICATION CKD SINCE 6 MONTHS ON CONSERVATIVE MANAGEMENT PERSONAL HISTORY : DIET :MIXED APPETITE : GOOD SLEEP : ADEQUATE BOWEL:REGULAR ALCHOL ISTORY- OCASSIONAL SINCE 20 YEARS STOPPED 6 MONTHS BACK GENERAL EXAMINATION : PATIENT IS CONSCIOUS , COHERENT , COOPERATIVE PALOR -NO PEDAL EDEMA - BILATERALLY PRESENT NO SIGNS OF CLUBBING , ICTERUS , CYANOSIS , LYMPHEDNOPATHY VITALS : TEMP : 986.8 F PR : 88 BPM BP : 210/100 MMHG GRBS : 133 MG / DL SPO2 : 98% RR : 21 CPM SYSTEMIC EXAMINATION : CVS : S1 , S2 HEARD , NO MURMURS RS : FINES CREPS PRESENT IN BILATERAL LOWER BACK PA :SOFT,NT, NO ORGANOMEGALY CNS : NFAD COURSE IN THE HOSPITAL: PATIENT WAS ADMITTED I/V/O COUGH SINCE 20 DAYS, FEVER SINCE 1 WEEK SHORTNSS OF BREATH SINCE 5 DAYS, B/L PEDAL EDEMA SINCE 30 DAYS, DECREASE URINE OUTPUT SINCE 1 DAY AND ALTERED SENSORIUM SINCE 8HRS AND WAS INVESTIGATED FURTHER AND ON EVALUATION WAS DIAGNOSED AS AKI SECONDARY TO LRTI ON CKD ( STAGE V) WITH HYPONATREMIA ( ? DILUSIONAL) WITH ANEMIA- MCHC, K/C/O HTN WITH RETINOPATHY. NEPHROLOGY REFERAL WAS DONE I/V/O SOB SINCE 5 DAYS WHICH IS GRADE II TO III MMRC AND B/L PEDAL EDEMA SINCE 3 DAYS. RX

FLUID RESTRICTION <1.5L/DAY SALT RESTRICTION <2 LIT/ DAY IVF 2 NS @ 50ML/HR INJ 3% NS @ 10ML/HR INJ PIPTAZ 2.25GM/IV/TID INJ LASIX 20ML/IV/BD TAB NICARDIA RETARD 20ML /PO/BD OPHTHAMOLOGY REFERRAL WAS DONE I/V/O RAISED ICP FEATURES, HYPERTENSIVE RETINOPATHY CHANGES FUNDUS EXAMINATION DONE ON 3/11/23 IMPRESSION- NO RAISED ICT FEATURES HYPERTNSIVE RETINOPATHY GRADE III CHANGES NOTED. Investigation COMPLETE URINE EXAMINATION (CUE) 03-11-2023 05:05:PM COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010 ALBUMIN ++ SUGAR + 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-RAPID03-11-2023 05:05:PM Negative Anti HCV Antibodies - RAPID03-11-2023 05:05:PM Non Reactive BLOOD UREA03-11-2023 05:05:PM 108 mg/dl 42-12 mg/dl SERUM CREATININE03-11-2023 05:05:PM 6.2 mg/dl 1.3-0.9 mg/dl SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 03-11-2023 05:05:PM SODIUM 99 mEq/L 145-136 mEq/L POTASSIUM 3.7 mEq/L 5.1-3.5 mEq/L CHLORIDE 92 mEq/L 98-107 mEq/L CALCIUM IONIZED 0.94 mmol/L mmol/L

USG WAS DONE ON 3/11/23: IMPRESSION: B/L GRADE III RPD CHANGES AND MIMINAL ASCITIS. MDCT BRAIN PLAIN - NO ABNORMALITY IN BRAIN-GENERALISED INCREASE IN BONE DENSITY, CONSISTENT WITH SKELETAL CHANGES OF CKD

Treatment Given(Enter only Generic Name) INJ CEFTRIAXONE 1GM IV/BD TAB.NICARDIA 10 MG PO/TID INJ.LASIX 40 MG IV/BD SYP.ASCORIL LS 10 ML PO/TID TAB NODOSIS 500 MG PO/TID TAB.SHELCAL 500MG PO/OD INJ IRON SUCROSE 200MG IN 100ML NS IV / ALTERNATE DAYS X 5 TIMES IN A WEEK SYP POTKLOR 10ML IN 1 GLASS OF WATER PO/TID Advice at Discharge INJ CEFTRIAXONE 1GM IV/BD TAB.NICARDIA 10 MG PO/TID INJ.LASIX 40 MG IV/BD SYP.ASCORIL LS 10 ML PO/TID TAB NODOSIS 500 MG PO/TID TAB.SHELCAL 500MG PO/OD INJ IRON SUCROSE 200MG IN 100ML NS IV / ALTERNATE DAYS X 5 TIMES IN A WEEK SYP POTKLOR 10ML IN 1 GLASS OF WATER PO/TID Follow Up REVIEW TO GM OPD AFTER 1 WEEK

Patient outcome:

GOOD RECOVERY AT ADMISSION.

Case 45:

70)F

Diagnosis

SEPTIC ENCEPHALOPATHY

DIABETIC NEPHROPATHY ON HEMODIALYSIS RIGHT EMPHYSEMATOUS PYELONEPHRITIS K/C/O DM2 AND HTN SINCE 8 YEARS K/C/O CVA 1 1/2 YEAR AGO WITH LEFT HEMIPERESIS 4 SESSIONS OF HD WITH 1 PRBC DONE. Case History and Clinical Findings COMPLAINTS OF DECREASED URINE OUTPUT SINCE 3 DAYS SOB SINCE 3 DAYS . PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS BACK THEN SHE DEVELOPED BREATHLESSNESS ,INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE GRADE 3 MMRC NOT RELIEVED AT REST. DECREASED URINE OUTPUT SINCE 3 DAYS ASSOCIATED WITH PEDAL EDEMA PITTING TYPE UPTO ANKLE HISTORY OF BLOATING SENSATION WITH ABDOMINAL DISTENSION HISTORY OF FEVER 1DAY BACK HIGH GRADE WITH CHILLS AND RIGORS NO HISTORY OF CHEST PAIN,PALPITATION ,EXCESSIVE SWEATING ,ORTHOPNEA PND NO HISTORY OF COUGH COLD VOMITING OUTSIDE CT ABDOMEN DONE SHOWED RIGHT EMPHYSEMATOUS PYELONEPHRITS PAST HISTORY: K/C/O OF DIABETES MELLITUS 2 AND HYPERTENSION SINCE 8 YEARS

KNOWN CASE OF CVA WITH LEFT HEMEPERESIS SINCE 1 1/2 YEARS NOT A KNOWN CASE OF CAD, ASTHMA, TB,THYROID . PERSONAL HISTORY : ALCHOHOLIC AND SMOKER STOPPED 1 YEAR AGO ON EXAMINATION : PATIENT IS CONSCIOUS ,COHERENT,COOPERATIVE . NO SIGNS OF PALLOR,ICTERUS,CYANOSIS ,GENERALISED LYMPHADENOPATHY. PEDAL EDEMA ,PITTING TYPE UPTO ANKLE TEMERATURE: PULSE RATE: BP: RESPIRATORY RATE: SPO2:98% ON RA GRBS:106MG/DL GAIT :HEMIPLEGIC RESPIRATORY SYSTEM: B/L AE CVS:S1 S2 HEARD CNS:NFND PA : SOFT, NON TENDER Investigation Name ValueNameValue COMPLETE URINE EXAMINATION (CUE) 15-04-2024 09:14:PM COLOUR Pale yellow APPEARANCE hazy REACTION Acidic SP.GRAVITY 1.010 ALBUMIN +++ Page-2 SUGAR

LIVER FUNCTION TEST (LFT) 15-04-2024 09:14:PM Total Bilurubin 1.03 mg/dl Direct Bilurubin 0.20 mg/dl SGOT(AST) 20 IU/L SGPT(ALT) 16 IU/L ALKALINE PHOSPHATASE 263 IU/L TOTAL PROTEINS 4.9 gm/dl Page-3 ALBUMIN

RFT 15-04-2024 11:59:PM UREA 160 mg/dl CREATININE 6.1 mg/dl URIC ACID 9.9 mmol/L CALCIUM 8.8 mg/dl PHOSPHOROUS 5.4 mg/dl SODIUM 136 mmol/L POTASSIUM 4.7 mmol/L. CHLORIDE 103 mmol/L ABG 17-04-2024 07:02:AM PH 7.12 PCO2 24.5

HEMOGRAM:HB:8.1TLC:29,500NEUTROPHILS:82LYMPHOCYTES:EOSINOPHILS:1MONOCYTES :9BASOPHILS:0PCV:22.8MCV:77.8MCH:27.6MCHC:35.5RBC COUNT:2.9PLATELET COUNT:3.2SMEAR:NORMOCYTIC NORMOCHROMICUSG ABDOMEN :MILD HEPATOMEGALY WITH GRADE 1 FATTY LIVERRIGHT RENAL CALCULI CAUSING MILD HYDRONEHROSISLEFT GRADE 1 RPD CHANGES .CT KUB:IMPRESSION:RIGHT SIDED EMPHYSEMATOUS PYELONEPHRITIS TYPE 2 (HUANG TSENG CLASS 3)PERINEPHRIC GAS MEDIAL TO RIGHT KIDNEYE/O GAS IN IVC -LIKELY EXTENSION VIA RENAL VEINE/O PERIDUODENAL GAS-MOST LIKELY DUE TO EXTENSION FROM PERINEPHRIC GAS HOWEVER SUGGESTED CLINICAL CORRELATION TO RULEOUT DUODENAL PERFORATION.RIGHT MILD HYDRONEPHROSIS WITH DILATED UPPER URETER UPTO A SUSPICIOUS CYST TISSUE DENSITY IN URETER AT THE JUNCTION OF UPPER AND MID URETER.SUGGEST CONTRAST CT OR CYSTOURETEROSCOPY TO RULE OUT TRANSITIONAL CELL CARCINOMA OF URETER2D ECHO:CONCENTRIC LVH+NO RWMAGOOD LV SYSTOLIC FUNCTION (EF:60%)GRADE 1 DIASTOLIC DYSFUNCTIONNOARMAC+,SCLEROTIC AV+NO PE/CLOTSIVC 1 CMS ,COLLAPSINGLA 2CM Treatment Given(Enter only Generic Name) RT FEEDS 100 ML WATER 2ND HOURLY ,100 ML MILK 4TH HOURLY INJ.MEROPENAM 500MG /IV/BD INJ.CLINDAMYCIN 600MG /IV/BD INJ.THIAMINE 200 MG IN 100 ML NS/IV/BD INJ PAN 40 IV/OD INJ NEOMAL 1GM IV/SOS (IF TEMP >101 F) INJ LASIX 40 MG IV/BD (IF BP.110 MMHG) T.ECOSPIRIN -AV 75/10 MG RT/H/S T.TAMSULOSIN 0.4 MG RT/OD T.NODOSIS 500MG RT/BD T.OROFER XT RT/OD T.SHELCAL CT RT/OD SYP.ALKASTONE B6 15ML/RT/TID Advice at Discharge RT FEEDS 100 ML WATER 2ND HOURLY ,100 ML MILK 4TH HOURLY INJ.MEROPENAM 500MG /IV/BD INJ.CLINDAMYCIN 600MG /IV/BD INJ.THIAMINE 200 MG IN 100 ML NS/IV/BD INJ PAN 40 IV/OD

INJ NEOMAL 1GM IV/SOS (IF TEMP >101 F) INJ LASIX 40 MG IV/BD (IF BP.110 MMHG) T.ECOSPIRIN -AV 75/10 MG RT/H/S T.TAMSULOSIN 0.4 MG RT/OD T.NODOSIS 500MG RT/BD T.OROFER XT RT/OD T.SHELCAL CT RT/OD SYP.ALKASTONE B6 15ML/RT/TID

Outcome:

Good recovery

Case 46:

50/F

Diagnosis TYPE 2 RESPIRATORY FAILURE SECONDARY TO ? ATYPICAL GBS WITH ISOLATED RESPIRATORY PARALYSIS

ALTERED SENSORIUM SECONDARY TO CO2,NARCOSIS

HEART' FAILURE WITH PRESERVED EJECTION FRACTION COMMUNITY ACQUIRED PNEUMONIA IN RIGHT MIDDLE AND LOWER LOBE (RESOLVED) B/L GRADE II BEDSORES KNOWN CASE OF HYPERTENSION SINCE 5 YEARS KNOWN CASE OF DIABETES SINCE 5 YEARS Case History and Clinical Findings 50 YEAR UNEMPLOYED RESIDENT OF NAKREKAL WAS BROUGHT TO CASUALTY WITH COMPLAINTS OF FEVER SINCE 5 DAYS COUGH SINCE 4 DAYS DIFFICULTY BREATHING SINCE 1 DAY PATIENT WAS APPARENTLY ASYMPTOMATIC UNTIL 5 DAYS AGO THEN HAD COMPLAINTS OF GENERALISED FEVER LOW GRADE NOT ASSOCIATED WITH CHILLS AND RIGOR NO DIURNAL VARIATIONS, INTERMITTENT, GRADUALLY PROGRESSIVE ASSOCIATED WITH COUGH- PRODUCTIVE WHITISH SPUTUM THICK CONSISTENCY, MUCOID, NON FOUL SMELLING, NON BLOOD STAINED, SHORTNESS OF BREATH GRADE 4 MMRC SINCE ONE DAY ,GENERALISED WEAKNESS. NO COMPLAINS OF ORTHOPNEA,PALPITATIONS,PROFUSE SWEWATING

NO COMPLAINS OF BURNING MICTURITION, INCREASED OR DECREASED URINE OUTPUT, PEDAL EDEMA NO COMPLAINS OF LOOSE STOOLS, NAUSEA, VOMITINGS NO HISTORY OF ANY MOSQUITO BITE, SCOPRION BITE PAST HISTORY HISTORY OF HOSPITALIZATION WITH?DENGUE ?SEPSIS 8 MONTHS AGO KNOWN CASE OF HYPERTENSION SINCE 5 YEARS ON UNKNOWN MEDICATION KNOWN CASE OF DIABETES ON TAB METFORMIN 500MG AND TAB GLIMIPERIDE 1 MG OD NOT A KNOWN CASE OF TB,THYROID,ASTHMA,CAD,CVA PERSONAL HISTORY LOSS OF APPETITE SINCE THREE DAYS DIET-NON VEGETERIAN BOWEL-CONSTIPATION SINCE THREE DAYS MICTURITION- NORMAL NO KNOWN ALLERGIES OCCASIONAL ALCOHOLIC NON SMOKER FAMILY HISTORY NO SIGNIFICANT FAMILY HISTORY MENSTRUAL HISTORY HYSTERECTOMY DONE 29YRS AGO GENERAL EXAMINATION NO PALLOR ICTERUS CYANOSIS CLUBBING AND LYMPHAEDENOPATHY VITALS AT TIME OF ADMISSION TEMP-100F PR: 80BPM BP:130/80MMHG RR: 20CPM

SPO2- 40% AT RA GRBS-221MG/DL R/S: BILATERAL AIR ENTRY PRESENT CREPTS IN RIGHT MAMMARY, LEFT IAA,ISA CVS: S1S2 HEARD NO MURMURS P/A: SOFT, NON TENDER CNS: NFND COURSE IN THE HOSPITAL THIS IS A CASE OF 50YR OLD FEMALE D. DHANAMMA, CAME WITH COMPLAINTS OF FEVER, SHORTNESS OF BREATH SINCE 4DAYS AND FACIAL PUFFINESS SINCE 3DAYS, WAS EVALUATED INITIALLY AND NECESSARY INVETIGATIONS WERE DONE. AND AS ABG WAS DONE, WHICH SHOWED TYPE II RESPIRATORY FAILURE WITH FLAPPING TREMORS SEEN IN PATIENT SECONDARY ?CO2 NARCOSIS, PATIENT WAS INITIALLY KEPT ON NIV. BUT AS THERE IS NO IMPROVEMENT IN ABG AND AS STILL CO2 LEVELS ARE INCREASING ON NIV, PATIENT WAS INTUBATED I/V/O TYPE II RESPIRATORY FAILURE, AND ON FURTHER INVESTIGATIONS DONE AND HRCT SHOWED CONSOLIDATION WITH ,MILD BRONCHIECTASIS IN BASAL SEGMENT OF RIGHT LOWER LOBE WAS DIAGNOSED WITH COMMUNITY ACQUIRED PNEUMONIA OF RIGHT MIDDLE AND LOWER LOBE ,HEART FAILURE WITH PRESERVED EJECTION FRACTION WITH A K/C/O T2DM &HYPERTENSION SO ANTIBIOTICS ,DIURETICS , IV FLUIDS AND OTHER SYMPTOMATIC AND SUPPORTIVE TREATMENT WAS GIVEN. DAY 3 PATIENT WAS STARTED WEANING TRIAL AS WEANING CRITERIA WAS MET,BUT COULDNT BE EXTUBATED BECAUSE OF RESPIRATORY DISTRESS AND HYPERCAPNIA WHEN PATIENT IS SHIFTED TO CPAP SO AGAIN SHIFTED BACK TO ACMV AND CONTINUED ON MV SUPPORT. PATIENT WAS EXTUBATED ON DAY 9 OF ADMISSION AS SHE IS COMPLETELY MAINTAINIG ON T PEICE WITHOUT ANY RESPIRATORY DISTRESS OR ANY ABG ABNORMALITIES AND COMPLETELY MET THE EXTUBATION CRITERIA WITH GCS OF E4VTM6. IMMEDIATELY AFTER 30MINS OF EXTUBATION, PATIENT HAD A SEIZURE EPISODE AND AFTER 1HR OF SEIZURE EPISODES, PATIENT DEVELOPED BRADYCARDIA AND WENT INTO CARDIAC ARREST FOLLOWED BY WHICH ROSC ACHIEVED AFTER 1 CYCLE OF CPR. POST REVIVAL AS PATIENT HAD AN EPISODE OF VENTRICULAR TACHYCARDIA, ANTI ARRHYTHMIC MEDICATION WERE GIVEN AND PATIENT WAS REINTUBATED. AS THERE IS A NEED A NEED FOR PROLONGED VENTILATOR SUPPORT, PERCUTANEOUS TRACHEOSTOMY WAS PLANNED AND DONE ON DAY 11 OF ADMISSION. THE PATIENT IS NOW ON TRACHEOSTOMY AND ON OTHER CONSERVATIVE MANAGEMENT WITH IV ANTIBIOTICS, ANTIPYRETICS, ANTIEPILEPTICS AND OTHER SUPPORTIVE MANAGEMENT.AS PATIENT IS IMPROVING WEANE OFF TRAIL WAS STARTED AND PATIENT IS BEING TREATED WITH INTERMITTENT CPAP AND OXYGEN SUPPORT. AS SATURATIONS WERE MAINTAINED TRACHEOSTOMY TUBE CAPPING DONE FOR REMOVAL AND OBSERVED 24HRS .NO HYPOXIA/RESPIRATORY DISTRESS WERE THERE,PATIENT IS HEMODYNAMICALLY STABLE WITH GCS E4V5M6 AND ABG WAS NORMAL SO TRACHEOSTOMY TUBE DECANULATED /REMOVED ON DAY22 DECANNULATIION OF TRACHEOSTOMY TUBE WAS DONE AND PATIENT IS TRAINED TO DO SPIROMETRY BREATHING EXERCISE TO INCREASE LUNG COMPLIANCE.ON DAY 6 PATIENT DEVELOPED B/L GRADE I BEDSORE INITIALLY UNILATERL BUTTOCK THEN BILATERAL BUTTOCK GRADE II BEDSORE FOR WHICH REGURAL DRESSING WAS DONE AND VAC DRESSING WAS DONE. CULTURES FROM BEDSORE WERE SENT AND ARE NEGATIVE. PLASTIC SURGEON OPINION WAS TAKEN FOR THE SAME AND ADVISED NO ACTIVE SURGICAL INTERVENTION, GOOD NUTRITIOUS DIET .PATIENT HAD DEVELOPED FEVER SPIKES FOR WHICH ANTIBIOTICS WAS STARTED. AS PATIENT IS HEMODYNAMICALLY STABLE PATIENT IS DISCHARGED ON 8/04/24 ON DAY 26 WITH HOME OXYGEN AND FOLLOWING ADVICE AT DISCHARGE. Investigation HEMOGRAM ON 13/3/24 ON 13/3/24 HB 14 TLC 14000 PLT 2.08 ON 15/3/24 HB 13.1 TLC 10 800 PLT 1.50 ON 16/3/24 HB 13.6 TLC 16000 PLT 1.5 ON 17/3/24 HB 11.9 TLC11 300 PLT 1.20

ON 18/3/24 HB 12.7 TLC12500 PLT1.20 ON 19/3/24 HB 12.0 TLC 9300 PLT 1.20 ON 20/3/24 HB 11.2 TLC 7400 PLT 1.35 ON 22/3/24 HB 11.3 TLC 8600 PLT 2.43 ON 23/3/24 HB 11.1 TLC 6300 PLT 3.14 ON 24/3/24 HB 11.3 TLC 7500 PLT 3.01 ON 27/3/24 HB 12.0 TLC 7200 PLT 3.02 RAPID HBSAG NEGATIVE HIV 1 AND 2 NEGATIVE RAPID HCV ANTIBODIES NEGATIVE Page-5 RFT ON 13/3/24

HRCT CHEST CONSOLIDATION WITH MILD BRONCHIECTASIS IN BASAL SEGMENT OF RIGHT LOWER LOBE BILATERAL MILD LOCULATED PLEURAL EFFUSION [R.L] F/S/O INFECTIVE ETIOLOGY ET CULTURE- NO GROWTH IS SEEN BLOOD C/S - NO GROWTH IS SEEN AFTER 1 WEEK OF AEROBIC INTUBATION AND 48 HRS OF AEROBIC INTUBATION WOUND SWAB C/S - NO GROWTH IS SEEN USG CHEST - B/L MILD PLEURAL EFFUSION ,CONSOLIDATORY CHANGES IN RIGHT LUNG USG ABDOMEN AND PELVIS GB SLUDGE MILD IHBRD

PROMINENT CBD RAISED ECHOGENECITY OF B/L KIDNEYS POST CPR 2D ECHO (CPR DONE ON 21/3/24) NO RWMA TRIVIAL TR,TRIVIAL AR,TRIVIAL MR MAC,SCLEROTIC AV,NO AS/MS EF= 64%,RVSP= 35MMHG GOOD LV SYSTOLIC FUNCTION GRADE I DIASTOLIC DYSFUNCTION IVC SIZE (0.9CMS) COLLAPSING Treatment Given(Enter only Generic Name) INJ.AUGMENTIN 1.2 GM IV/TID X 7 DAYS INJ. FENTANYL 2 AMP + 46 ML NS INJ. ATRACURIUM 2 AMP + 45 ML NS INJ.LEVOFLOXACIB X 6 DAYS INJ.HUMAN ACTRAPID INSULIN S/C TID PREMEALS ACC TO GRBS INJ.HYDROCORT 100MG IV OD INJ.LASIX 20 MG IV TID IF SBP >100MMHG TAB.GLYCOPYROLATE 0.5 MG PO/TID TAB.HIFENAC SP PO/BD TAB.FLUVIR 75MG X 6 DAYS TAB.AZITHROMYCIN X 7 DAYS TAB.MONOCEF X 8 DAYS TAB.PAN D 40MG PO/OD TAB.PCM 650 MG PO/BD TAB.PULMOCLEAR PO/BD TAB.MONTEK LC PO/HS TAB.BENFOMET PLUS PO/OD TAB .ULTRACET 1/2 TAB PO/BD TAB.TUS-MD PO/TID SYP.GRILINCTUS 15ML PO/TID SYP.MUCAINE GEL 15ML PO/TID NEB WITH MUCOMIST 8 TH HRLY , DUOLIN-6TH HOURLY , BUDECORT- 8TH HRLY DICLOFENAC TD PATCH BD

OINT THROMBOPHEBE FOR L/A OINT ZYTEE GEL FOR L/A GRBS 7 POINT PROFILE SPIROMETRY BREATHING EXERCISE CHEST PHYSIOTHERAPY ET SUCTIONING POSITION CHANGE BED SORE DRESSING DVT STOCKING AIR BED Advice at Discharge TAB AUGMENTIN 625MG PO BD 1-0-1 X 4 DAYS TAB.GLYCOPYROLATE 0.5 MG PO/TID X 3DAYS TAB LEVIPIL 500MG BD X 3 MONTHS TAB METFORMIN 500MG PO/BD TO CONTINUE TAB.PAN D PO/OD X 5DAYS TAB DYTOR PLUS 10/50 PO/OD 1-0-0 TO CONTINUE TAB DYTOR 10 MG PO/OD 0-0-1 TO CONTINUE SYP CITAL UTI 20ML IN 1 GLASS OF WATER PO/TID 1-1-1 X 5 DAYS TAB DOLO 650MG PO/BD X 3 DAYS TAB.PULMOCLEAR PO/BD X 7DAYS TAB.MONTEK LC PO/HS X 5DAYS TAB.BENFOMET PLUS PO/ODX 7 DAYS FOROCORT 200MCG 2 PUFFS BD HOME OXYGEN @ 1-2LITS WHILE SLEEPING SPIROMETRY BREATHING EXERCISE DAILY BEDSORE DRESSING WITH MEGAHEAL OINT AND CUTICELL SOFT DIET AMBULATION

Patient outcome:

GOOD RECOVERY DURING DISCHARGE

DIED AFTER 45 DAYS AFTER DISCHARGE

Case 47:

62,M

Diagnosis HEART FAILURE WITH REDUCED EJECTION FRACTION [EF = 37%] WITH ANASARCA WITH K/C/O HYPETENSION SINCE 2 YEARS WITH H/O CVA [ LEFT SIDED HEMIPARESIS] 14 YEARS AGO

ALTERED SENSORIUM SECONDARY TO CVA

. WITHBORGANIC PERSONALITY DISORDER WITH TOBACCO DEPENDENCY SYNDROME. Case History and Clinical Findings Patient came with the complaints of pedal edema and scrotal swelling since 2 monthsshortness of breath since 2 monthsPatient was apparently alright 1 year ago, then he developed weakness of right upper and lower Limb and deviation of mouth to right side and started talking irrelevantly MRI brain imaging was done which showed infarcts.Pt. used allopathic as well as herbal medication and weakness gradually improved by 6 months. patient has fluctuating sensorium since then which has worsened since 2 months. complain of pedal edema and scrotal swelling since 2 months insidious onset gradually progressive in nature up to nice fitting type continuous and nature know their regional variation with shortness of breath with incidence in launching on set manually progressive signature on ordinary activity great to grade 2orthopnea present pnd presentNot complain of chest pain, palpitations ,fever vomiting loose stoolsPt is a known case of hypertension since 2 years (not on medication. )Not a known case of DM TB asthma SEIZURES thyroid disorders. GENERAL EXAMINATION: PATIENT IS CONSIOUS, COHERENT AND COOPERATIVE NO PALLOR, ICTERUS,CLUBBING, CYNOSIS, LYMPADENOPATHY

VITALS: BP:130/80MMHG PR: 74BPM RR:18CPM SPO2:96%' GRBS :164 MG% SYSTEMIC EXAMINATION: CVS S1, S2+ NO MURMURS HEARD RS: BAE+ ,CREPTS PRESENT IN RIGHT IAA P/A: SOFT NON TENDER CNS:NFND PT. CAME WITH THE ABOVE MENTIONED COMPLAINTS, THOROUGH CLINICAL EXAMINATION AND LABORATORY INVESTIGATIONS WERE DONE BLOOD AND URINE WERE SENT. 2 D ECHO - EF 35% MODERATE TR WITH PAH , MODERATE MR, MODERATE AR RWMA + , NO AS/MS ,SCLEROTIC AV GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION PT IS DIAGNOSED WITH HEART FAILURE WITH REDUCED EJECTION FRACTION . PT. WAS STARTED ON PRE-LOAD AND AFTER LOAD REDUCING DRUGS. PT. 10 KGS LOST 10KGS AND PEDAL EDEMA AND SHORTNESS OF BREADTH SUBSIDEDPSYCHIATRY REFFERAL WAS DONE I/V/O AGGRESIVE BEHAVIOUR SINCE 1 YEAR AND WAS DIAGNOSED WITH 1.ORGANIC PERSONALITY DISORDER 2. TOBACCO DEPENDANCE SYNDROME AND WAS ADVISED TAB. DIVLPROATE SODIUM 250MG BD, TAB. LORAZEPAM 1MG , NICOTINE LOZENGES 2MG PO/SOS. PT. IMPROVED SYMPTOMATICALLY DURING THE STAY IN THE HOSPITAL PT. IS BEING DISCHARED IN HEMODYNAMICALLY STABLE CONDITION Investigation USG ABDOMEN - GROSS ASCITIS B/L GRADE 1 RPD CHANGES

B/L PLEURAL EFFUSION [R>L] INCREASED WALL THICKNESS OF GALL BLADDER SUBCUTANEOUS EDEMA IN THE ANTERIOR ABDOMINAL WALL 2 D ECHO - EF 35% MODERATE TR WITH PAH , MODERATE MR, MODERATE AR RWMA + , NO AS/MS ,SCLEROTIC AV GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION FBS - 103 MG/DL RFT : UREA- 24 CREATININE-1.0 SODIUM-137 POTASSIUM-4.2 CHLORIDE-101 HEMOGRAM : HB - 9.6 TLC - 5200 PLC -1.95 CUE : SUGAR NIL ALBUMIN NIL PUS CELLS 2-4 EC 2-3 Advice at Discharge FLUID RESTRICTION <1.5L/DAYSALT RESTRICTION <2G/DAYINJ. LASIX 40 IV/BDT. MET-XL 12.5 MG PO/ODT. ECOSPRIN AV 75 MG PO/ODT. TELMA 20MG/PO/ODT. EMPAGLIFOCIN 100 ML PO/ODTAB. DIVALPROATE SODIUM 250MG PO/ BDTAB. LORAZEPAM 1 MGPO/ODNICOTINE LOSENZES PO/SOS

Patient outcome:

GOOD RECOVERY OF SENSORIUM AT DISCHARGE

Case 48:

51,F

Diagnosis 1 DENGUE HEMORRHAGIC FEVER OR EXPANDED DENGUE FEVER WITH POLYSEROSITIS ( RESOLVED ) 2 ALTERED SENSORIUM (RESOLVED ) SECONDARY TO ? DENGUE ENCEPHALITIS /HEPATIC/UREMIC ENCEPHALOPATHY 3 PRE RENAL AKI(RESOLEVD) 4 ACUTE LIVER INJURY 6 GRADE II BEDSORES 7 KNOWN CASE OF TYPE 2 DM Case History and Clinical Findings CHIEF COMPLAINTS : C/O DRY COUGH SINCE 7 DAYS C/O SOB SINCE 4 DAYS C/O ABDOMINAL DISTENSION SINCE 4 DAYS C/O DECRAESED URINE OUT PUT SINCE 4 DAYS HOPI PATIENT WAS APPARENTLY ALRIGHT 7 DAYS BACK THEN SHE DEVELOPED FEVER ASSOCIATED WITH CHILLS AINSIDIOUS IN ONSET NOT ASSOCIATED WITH MYALGIA OR ARTHRALGIA H/O DRY COUGH SINCE 7 DAYS , NO SEASONAL VARIATION OR DIURNAL VARIATION, NOT ASSOCIATED WITH BLOOD,FEVER ASSOCIATED WITH DECREASE IN APPETITE ON DAY 1 OF ILLNESS SHE SOUGHT CONSULTATION FOR RMP AND WAS TAKING TREATMENT ON DAY3 OF ILLNESS SHE WAS HAVING SOB GRADUALLY PROGRESSIVE FROM GRADE 1 TO 5 ON NYHA H/O ABDOMINAL DISTENSION SINCE 4 DAYS GRADUALLY PROGRESIVE TO PRESENT SIZE ASSOCIATED WITH ABDOMINAL PAIN H/O DECRESED URINARY OUT PUT SINCE 4 DAYS NO HEMATURIA, BLOOD IN STOOLS, OR OTHER BLEEDING MANIFESTATIONS COMPLAINTS PAST HISTORY : K/C/O DM SINCE 1 YEAR NOT A K/C/O DM, TB, ASTHMA, TB, EPILEPSY, HYPERTENSION PERSONAL HISTORY : APPETITE : NORMAL DIET : MIXED BOWEL AND BLADDER : REGULAR SLEEP : ADEQUATE ADDICTIONS : OCCASIONAL ALCOHOLIC AND TODDY DRINKER MENSTRUAL HISTORY : AGE OF MENARCHE : 13 YEARS CYCLES : REGULAR ATTAINED MENOPAUSE OBSTRETRIC HISTORY : NULLIPAROUS GENERAL EXAMINATION : PATIENT WAS CONSCIOUS , COHERENT COOPERATIVE PETECHIAE PRESENT VITALS : TEMP : AFEBRILE BP :130/80 MMHG HR : 78BPM SPO2 : 98% ON RA

Patient outcome:. GOOD RECOVERY AT DISCHARGE

Case 49:

74/M

Today’s admission

ICU bed 1 :

A 74 years old male patient,resident of kondaram ,gauraram mandal nalgonda district,married 50years ago,who is an agricultural labourer by occupation(plant paddy ,cotton )was referred from outside hospital,in view of lost of speech since 10 days.

He was apparantly assymptomatic 25 years ago,then he went to bombay to her sisters house who stays there,and on his return to his kondaram village,got fever for 1 week and relieved on medication and on routine investigations was diagnosed as having OHA since then,initially 1tablet per day and on futhur followup increased the dosage to 1——-X———1/2 tab,and was apparantly assymptomatic till 17 years ago and then developed pedal Edema till knees,yellowish discolouration of eyes and shortness of breath on exertion for which he got admitted in our hospital for 8 days and was managed conservatively,and was asymptomatic for 7 years and then 10years ago,he had history of fever ,low grade associated with evening rise of temperature and cough for 10 days and was diagnosed as ?sputum positive tuberculosis and was treated with ATT for 2 years(acc to his wife),and was assymptomatic 3 years back and then developed pain in the right loin for 10 days for which they went to local hospital and told as having a renal calculi and was kept on conservative management but the pain didn’t subsided even on using medication for 6 days and then ?stent /?foleys was placed ,but still his pain didn’t subsided associated with new onset fever,and then they removed the placed stent ,but still the pain at the right loin persisted a surgery was done?lithotripsy ,and then again went to other hospital as they were told that calculi wasn’t removed completely and again stent was placed >>it got infected and seen as pus filled mass at the right loin and then surgery was done and pain got relieved,and he was alright till 4 mnths and then he had a small abrasion /small crack over left second toe initially and then he got injured to the same finger by accidentally hitting it to wall,>>>swelling over that finger >>>blackish discoloured in 8days>>>amputated the second toe,and the skin of the adjacent toe was also removed,at the same time he had left hand dragging pain for which investigations were done and treated with muscle relaxants and PPIs and after 2 days due to imbalance over that amputated foot ,he had history of fall at 2:00am in the night when he went to washroom,and went lo hospital and was told as ?Intertrochantric fracture and ?hemiarthroplasty was done,and during the postoperative period patient used to have brief episodes of altered sensorium over a transient period,for which an MRI /CT was done and was told as having an extraaxial mass in the brain(?neoplasm),and the episodes of altered sensorium/hallucinations once/twice in a week(Eg:He mistakened the hanged clothes as persons,and used to talk with persons who expired)

And 2 months ago ,he developed pain in the right hypochondrium dragging type and got admitted in hospital and was treated conservatively for 10 days,and told as having ?cholelithiasis ,and 10 days ago in the afternoon he ate rice and at 3:00pm he had a pomegranate fruit and at 4:00pm he was sleeping on the bed and when his wife called her,he had no response on calling him(lost his speech),(eyes open )and she thought it as hypoglycaemic episode and poured sugar in his mouth but he was not having it,and at the same time he had involuntary rolling over the bed and stiffened mouth(unable to open) and had involuntary micturition at that time and rmp arrived and his Bp and grbs was normal and they took them to hospital and during travelling he had deviation of mouth to right,they(attenders)thought it as hemiparesis,and at hospital his SBP was 240mmHg,and on medication the deviation got corrected and on day 2 of admission due to decrease in saturation ,patient was intubated on 8-7-2023 and extubated on 14-07-2023.

Post extubation,no return of his speech and there were absent tongue moments also.

K/c/o Diabetes since 15 years,on OHA initially,shifted to insulin since 1 year.

K/c/o CKD since 4mnths and on conservative management

On regular checkup was diagnosed as having hypertension since 2 years and on regular medication.

Diet is mixed

Previously he used to have,gatka in mrng and rice in afternoon and night,but since 4mnths gatka in the mrng,rice afternoon,java at 3pm and at 8pm.

Decreased Apetite since 20 days.

Constipation since 15days

Chronic Alcohol intake for 30years stopped 3 years ago ,smoker for 20 years stopped 2 years ago.

At the time of presentation:

Pt is confused

GCS:E4V1M6

BP:150/70mmHg

PR:98bpm

RR:18cpm

RS:clear lungs

CNS:

Pt is obeying commands

Bilateral pupils normal in size and reacting to light.

Tone increased in bilateral upperlimbs

Normal in lowerlimbs

Power:couldn’t be elicited

But moving all 4 limbs to pain

Reflexes:

++ in both biceps,triceps and Supinator.

Bilateral lowerlimb reflexes absent.

Patient developed xerosis/dryskin over bilateral palms and legs and soles(since the past 10 days of his ICU admission)

Final diagnosis:

Aphasia (Global)secondary to mass in right frontal lobe

With acute kidney injury on CKD

Investigations- (09/07/2023)

MRI BRAIN

On 10/07/2023

UsG- Abdomen

On 11/07/23

On 12/07/23

MRI BRAIN -

HRCT CHEST-

On 13/07/23

On 14/07/23

On 15/07/23-

On 16/07/23-

On 17/07/23-

INVESTIGATIONS-

On 18/07/23

FASTING BLOOD SUGAR - 139mg/dl

On 19/07/23

BLOOD UREA - 50mg/dL

SERUM CREATININE-2.3mg/dl

SERUM URIC ACID - 7.5 mg%

On 20/07/23

Referrals-

1. Orthopaedic referral-

In view of left hip hemiarthroplasty

2. Ophthalmology referral-

in view of diabetic and hypertensive retinopathy

Questions around this patient :

1)cause of his sudden aphasia,

2)If the mass in the frontal lobe is the cause,why would it cause sudden aphasia?

3)cause for his hypertonia of his upperlimbs

Starter Answers :

1) Compression of motor and sensory speech areas due to focal raised ICT caused by the focal lesion

2) Sudden rise of focal pressure such as bleed into the mass or infarct into the mass or if the mass was a living parasite, it's sudden death and consequent inflammation

3) Compression of the inhibitory interneurons in the UMN pyramidal fibers traversing the subcortical areas of the frontal lobe as well as brain stem

Plan:For Steriotactic biopsy

Coming to complexities sir:

They live in a house in kondaram,own house

The patient had one younger sister ,and his wife has two brothers and one sister.

The first insult was 50years ago,as they tried for children visited many hospitals but they didn’t have any children.

And they have no agricultural land for themselves, they have 2 buffaloes where they could earn some money by selling their milk,but he sold them 20 years ago,as he was diagnosed as diabetes(and found himself weak and that was when he stopped working)and due to financial issues.

And other insult was 3 years ago,when he lost his younger sister(died due to ?seizures?paralysis with uncontrolled diabetes),and some Arguements went on after her sister death,because they have many loan’s (as she died without clearing those)

And other insult was 3 years ago when they got their kidney operation for renal calculi,where they have spend 4lakh rupees

Other insult,when he got his finger amputation (spend Rs:53,000/-)

And for hemiarthroplasty for which they spend (Rs:40,000/-)

For cholilithiasis(Rs:42,000/-)

During all these period as the patient is consious and well oriented he used to say to his wife ,that his savings are getting over.

These are the insults faced by the patient uptill 6-07-2023.

And then now insult to his wife,as they spend 2lakh rupees in outside prvt hospital and acc to his wife,now they are getting money frm her brothers

Patient Outcome:

Aphasia resolved on followup and sensorium resolved.

Case 50:

60)F

PATIENT WAS BROUGHT TO CASUALITY IN UNRESPONSIVE STATE.

PATIEN WAS APPARENTLY ASYMPTOMATIC 3 YEARS BACK THEN SHE DEVELOPED GENERALISED WEAKNESS FOR WHICH SHE VISITED LOCAL HOSPITAL AND WAS DIAGNOSED WITH TYPE 2 DM. SINCE THEN PATIENT WAS ON IRREGULAR MEDICATION. TODAY MORNING PATIENT ATTENDERS NOTICED THAT PATIENT WAS IN UNRESPONSIVE STATE AND WAS UNABLE TO WAKEUP FROM SLEEP AND WAS TAKEN TO LOCAL RMP (HIGH SUGARS 600 MG/DL WAS OBSERVED) AND WAS REFERRED TO OUR HOSPITAL IN UNRESPONSIVE STATE, HER GCS - E1V1M6.

NO H/O ABNORMAL MOVEMENTS, HEADACHE,VOMITING. K/C/O DM2 SINCE 3 YRS AND ON IRREGULAR MEDICATION.

NOT K/C/O HTN,ASTHMA, CAD, EPILEPSY. PERSONAL HISTORY :

APPETITE - NORMAL

DIET - MIXED

BOWEL AND BLADDER - REGULAR

SLEEP - ADEQUATE

ADDICTIONS : OCCASIONAL TODDY-ONCE A WEEK

TOBACCO(BEEDI) FROM 20 YEARS, STOPPED 3 YEARS AGO

GENERAL EXAMINATION :

NO PALLOR, ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY,PEDAL EDEMA

VITALS ON ADMISSION:

TEMP- 101 F

PR-90 BPM

BP- 100/70MM HG

RR- 20 CPM

SPO2- 97% AT RA

GRBS - 226 MG/DL

VITALS ON ADMISSION:

TEMP- 101 F

PR-90 BPM

BP- 100/70MM HG

RR- 20 CPM

SPO2- 97% AT RA

GRBS - 226 MG/DL

SYSTEMIC EXAMINATION:

1) PER ABDOMEN:

INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.

PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.

ASCULTATION: BOWEL SOUNDS - HEARD

2)RESPIRATORY SYSTEM:

INSPECTION:SHAPE OF THE CHEST IS ELLIPTICAL,B/L SYMMETRICAL.BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.

PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL .VOCAL FREMITUS IS NORMAL

PERCUSSION: RESONANT B/L

ASCULTATION: BAE + , NVBS HEARD

3) CVS:

INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.

PALPATION: APEX BEAT FELT IN LEFT 5TH ICS.NO THRILLS AND PARASTERNAL HEAVES.

ASCULTATION: S1S2 +,NO MURMURS

4) CNS:

GCS - E1V1M6

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEM- NORMAL,

MOTOR SYSTEM: TONE- NORMAL, POWER- 0/5 IN RIGHT UL AND LL , 2/5 IN LEFT UL AND LL REFLEXES : BICEPS - 1+ , TRICEPS-1+ , SUPINATOR - 1+ ,KNEE - 1+ , ANKLE - 1+

Investigations:

1)HEMOGRAM:

29/01/23

HB : 13.0 mg/dl

PCV : 24.8%

TLC : 13500 CELLS/CUMM PLAT: 1.8 LAKH/CUMM 30/01/23

HB : 11.1 mg/dl

PCV : 34.5%

TLC : 13400 CELLS/CUMM PLT : 1.7 LAKH/CUMM 31/01/23

HB : 10.6 mg/dl

PCV: 33.1 %

TLC : 6900 CELLS/CUMM PLT : 1.7 LAKH/CUMM

01/012/23

HB : 10.8 mg/dl

PCV : 33.3%

TLC : 6700 CELLS/CUMM

PLT : 2.1 LAKH/CUMM

ABG ON 28-01-2023 (04:15:PM)

PH 4.50

PCO2 30.4

PO2 76.6

HCO3 24.0

St.HCO3 : 26.3

BEB : 2.2

BEecf : 1.2

TCO2 : 46.0

O2 Sat : 95.7

O2 Count : 19.5

Serum creatinine :1.2mg/dl

PHOSPHOROUS 28-01-2023:-2.0 mg/dl

HBsAg-RAPID: Negative

HIV : Negative

ANTI HCV : Negative

BLOOD UREA : 28- 56 mg/dl

SERUM ELECTROLYTES —

SODIUM ; POTASSIUM ; CHLORIDE ; CALCIUM

143 mEq/L ; 3.0 mEq/L ; 105 mEq/L ;1.05 mmol/L

LFT:

Total Bilurubin :1.07 mg/dl

DB: 0.20 mg/dl

AST:24 IU/L

ALT: 13 IU/L

ALP: 143 IU/L

TP:6.2 gm/dl

ALB:3.0 gm/dl

A/G: 0.89

2)USG ABDOMEN: NO SONOLOGICAL ABNORMALITY DETECTED 3)USG NECK: TRIRADS 3 LESION IN RIGHT LOBE OF THYROID

TRIRADS 2 LESION IN LEFT LOBE OF THYROID 4)BLOOD C/S : NO GROWTH SEEN

5)URINE C/S : E.COLI ISOLATED.

6)2D ECHO : NO RWMA , CONCENTRIC LVH+

TRIVIAL TR+/MR+/AR+

NO AS, MS

EF=62%

GOOD LV SYSTOLIC FUNCTION, DIASTOLIC DYSFUNCTION +, NO PE,PAH.

Diagnosis:

? SEPTIC ENCEPHALOPATHY (SECONDARY TO UROSEPSIS) WITH HYPERGLYCEMIA (RESOLVED) WITH TYPE 2 DM

Treatment :

1.IVF - NS@ 75ML/HR

2.INJ.PIPTAZ 4.5 GM IV/TID

3.T NITROFURONTOIN 100 MG PO/BD

4.INJ PAN 40 MG IV OD

5.INJ KCL 20 MEQ IN 100 ML NS

6.INJ MAGNESIUM 1 AMP IN 100 ML NS

7.T DOLO 650 MG PO/TID

8.SYP POTCHLOR 10 ML PO/TID

9.INJ HAI S/C ACCORDING TO GRBS

Patient outcome:GOOD RECOVERY AT DISCHARGE

Medicine Department

Sunday, July 7, 2024

50 deidentified Case report forms of the Narketpally altered sensorium outcomes project

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