fever projr unclassified 45/F

 unclassified 

date of admission : 21/04/2024

date of discharge : 23/05/2024 

discharge type : LAMA 






Diagnosis

1.SEPTIC ENCEPHALOPATHY

2.CKD ON MHD

3.K/C/O HYPERTENSION , HYPOTHYROIDISM

4.GRADE II BED SORE

Case History and Clinical Findings

CHIEF COMPLAINTS

C/O PEDAL EDEMA SINCE 1YEAR

C/O FEVER SINCE 1WEEK

HOPI

PATIENT WAS APPARENTLY ASYMPTOMATIC 7YEARS AGO THEN SHE HAD C/O LOW BACKACHE AND B/L KNEE JOINT PAIN FOR WHICH SHE STARTED NSAIDS. C/O B/L LOWER LIMB SWELLING PITTING TYPE, INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE , INITIALLY GRADE I AND RELIEVED ON WALKING AND ELEVATION .C/O FEVER SINCE 1WEEK INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE AND ASSOCIATED WITH CHILLS AND RIGORS.PATIENT HAD FEVER SINCE 1MONTH THEN CAME FOR MAINTENANCE HEMODIALYSIS AFTER 2HOURS OF DIALYSIS PATIENT BECAME ALTERED AND WAS TREATED ACCORDINGLY PATIENT HAD CONTINUOUS HIGH GRADE FEVER SPIKES AND NECESSARY ANTIBIOTICS WERWE GIVEN AND DIALYSIS WAS DONE EVERYDAY.PATIENT GCS FLUCTUATED DURING THE COURSE IN THE HOSPITAL ACCORDING TO TLC COUNT ON 23/5/24 DURING DIALYSIS PATIENT HAD CARDIAC ARREST CPR WAS DONE AND ROSC WAS ACHIEVED AND WAS INTUBATED . PATIENT ATTENDERS LEFT AGAINST MEDICAL ADVICE.

PAST HISTORY

K/C/O CKD

K/C/O HTN ON MEDICATION (TAB.NICARDIA 20MG)

NOT A K/C/O DM, ASTHMA, EPILEPSY

GENERAL EXAMINATION

PATIENT IS C/C/C

NO PALLOR ,ICTERUS, CYANOSIS ,CLUBBING ,LYMPHADENOPATHY ,OEDEMA OF FEET

VITALS

BP 120/80MMHG

PR 100 BPM

RR 18 CPM

TEMPERATURE 97 F

STSTEMIC EXAMINATION

RS ; BAE PRESENT , NVBS HEARD

CVS ;S1 ,S2 HEARED

CNS ; NFND

PA ; SOFT NON TENDER

Investigations 

HB TC N L E M B PLT SMEARLIVER FUNCTION TEST (LFT) 21-04-2024 04:23:PM Total Bilurubin1.05 mg/dlDirect Bilurubin0.20 mg/dlSGOT(AST)12 IU/LSGPT(ALT)10 IU/LALKALINE PHOSPHATASE339 IU/LTOTAL PROTEINS6.2 gm/dlALBUMIN2.91 gm/dlA/G RATIO0.88RFT 21- 04-2024 04:23:PM UREA132 mg/dlCREATININE8.3 mg/dlURIC ACID6.9 mmol/LCALCIUM9.9 mg/dlPHOSPHOROUS4.8 mg/dlSODIUM139 mmol/LPOTASSIUM4.8 mmol/L.CHLORIDE103 mmol/LCOMPLETE URINE EXAMINATION (CUE) 21-04-2024 04:23:PM COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN+++SUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS4-5EPITHELIAL CELLS3-4RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilHBsAg-RAPID21- 04-2024 04:23:PMNegative Anti HCV Antibodies - RAPID22-04-2024 05:11:PMNon Reactive RFT 12-05-2024 12:02:AM UREA44 mg/dlCREATININE4.0 mg/dlURIC ACID5.4 mmol/LCALCIUM10.0 mg/dlPHOSPHOROUS4.9 mg/dlSODIUM130 mmol/LPOTASSIUM3.9 mmol/L.CHLORIDE98 mmol/LCOMPLETE URINE EXAMINATION (CUE) 12-05-2024 04:09:PM COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN+SUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS3-4EPITHELIAL CELLS2-3RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilRFT 13-05-2024 01:07:PM UREA98 mg/dlCREATININE5.2 mg/dlURIC ACID7.9 mmol/LCALCIUM10.0 mg/dlPHOSPHOROUS6.6 mg/dlSODIUM132 mmol/LPOTASSIUM4.2 mmol/L.CHLORIDE98 mmol/LCOMPLETE BLOOD PICTURE (CBP) 13-05-2024 10:32:PM HAEMOGLOBIN10.1 gm/dlTOTAL COUNT48000 cells/cummNEUTROPHILS91 %LYMPHOCYTES02 %EOSINOPHILS01 %MONOCYTES06 %BASOPHILS00 %PLATELET COUNT5.7SMEARNormocytic normochromic anemia with neutrophilic leukocytosis and thrombocytosisRFT 13-05-2024 10:32:PM UREA82 mg/dlCREATININE3.4 mg/dlURIC ACID5.0 mmol/LCALCIUM9.8 mg/dlPHOSPHOROUS4.3 mg/dlSODIUM141 mmol/LPOTASSIUM3.5 mmol/L.CHLORIDE101 mmol/LABG 14-05-2024 12:33:AM PH7.48PCO228.3PO2119HCO320.9St.HCO323.3BEB-1.3BEecf-2.1TCO242.0O2 Sat98.1O2 Count15.9ABG 14-05-2024 12:14:PM PH7.49PCO229.1PO2107HCO322.3St.HCO324.6BEB0.3BEecf-0.6TCO244.4O2 Sat97.4O2 Count16.4

A BG 15-05-2024 12:34:AM PH7.41PCO232.9PO251.3HCO320.5St.HCO321.7BEB-3.0BEecf- 3.4TCO242.2O2 Sat86.4O2 Count12.9RFT 15-05-2024 12:34:AM UREA21 mg/dlCREATININE2.5 mg/dlURIC ACID3.1 mmol/LCALCIUM9.3 mg/dlPHOSPHOROUS3.8 mg/dlSODIUM139 mmol/LPOTASSIUM3.4 mmol/L.CHLORIDE99 mmol/LABG 15-05-2024 09:48:PM PH7.35PCO227.1PO243.6HCO314.6St.HCO316.6BEB-9.4BEecf-9.9TCO230.6O2 Sat78.5O2 Count11.6RFT 15-05-2024 09:48:PM UREA41 mg/dlCREATININE3.6 mg/dlURIC ACID2.7 mmol/LCALCIUM9.8 mg/dlPHOSPHOROUS4.3 mg/dlSODIUM140 mmol/LPOTASSIUM3.5 mmol/L.CHLORIDE103 mmol/LABG 16-05-2024 10:43:PM PH7.41PCO223.4PO240.0HCO314.6St.HCO317.3BEB-8.4BEecf-9.2TCO230.4O2 Sat77.7O2 Count10.9RFT 16-05-2024 10:43:PM UREA24 mg/dlCREATININE2.0 mg/dlURIC ACID2.1 mmol/LCALCIUM9.0 mg/dlPHOSPHOROUS3.1 mg/dlSODIUM140 mmol/LPOTASSIUM3.3 mmol/L.CHLORIDE104 mmol/LABG 17-05-2024 10:52:PM PH7.446PCO229.9PO268.7HCO320.3St.HCO322.1BEB-2.7BEecf-3.2TCO242.0O2 Sat95.3O2 Count12.9RFT 17-05-2024 10:52:PM UREA15 mg/dlCREATININE1.7 mg/dlURIC ACID2.0 mmol/LCALCIUM10.0 mg/dlPHOSPHOROUS2.9 mg/dlSODIUM140 mmol/LPOTASSIUM3.2 mmol/L.CHLORIDE105 mmol/LLIVER FUNCTION TEST (LFT) 18-05-2024 10:45:PM Total Bilurubin2.34 mg/dlDirect Bilurubin1.89 mg/dlSGOT(AST)153 IU/LSGPT(ALT)28 IU/LALKALINE PHOSPHATASE975 IU/LTOTAL PROTEINS4.8 gm/dlALBUMIN2.0 gm/dlA/G RATIO0.71RFT 18-05- 2024 10:45:PM UREA14 mg/dlCREATININE1.5 mg/dlURIC ACID2.0 mmol/LCALCIUM10.0 mg/dlPHOSPHOROUS3.0 mg/dlSODIUM140 mmol/LPOTASSIUM3.2 mmol/L.CHLORIDE105 mmol/LRFT 19-05-2024 10:38:PM UREA30 mg/dlCREATININE2.3 mg/dlURIC ACID2.0 mmol/LCALCIUM10.0 mg/dlPHOSPHOROUS4.2 mg/dlSODIUM138 mmol/LPOTASSIUM3.2 mmol/L.CHLORIDE103 mmol/LCOMPLETE BLOOD PICTURE (CBP) 20-05-2024 10:02:PM HAEMOGLOBIN9.1 gm/dlTOTAL COUNT43000 cells/cummNEUTROPHILS92 %LYMPHOCYTES05 %EOSINOPHILS01 %MONOCYTES02 %BASOPHILS00 %PLATELET COUNT3.7SMEARNormocytic normochromic anemia with neutrophilic leucocytosisT3, T4, TSH 20- 05-2024 10:02:PM T30.23 ng/mlT42.76 micro g/dlTSH6.34 micro Iu/mlABG 21-05-2024 10:12:AM PH7.48PCO2

25.0PO267.6HCO318.6St.HCO321.5BEB-3.5BEecf-4.3TCO238.0O2 Sat95.7O2 Count13.7LIVER FUNCTION TEST (LFT) 21-05-2024 10:56:PM Total Bilurubin1.94 mg/dlDirect Bilurubin0.95 mg/dlSGOT(AST)82 IU/LSGPT(ALT)15 IU/LALKALINE PHOSPHATASE1362 IU/LTOTAL PROTEINS4.9 gm/dlALBUMIN1.98 gm/dlA/G RATIO0.68RFT 21-05-2024 10:56:PM UREA26 mg/dlCREATININE1.6 mg/dlURIC ACID1.8 mmol/LCALCIUM9.9 mg/dlPHOSPHOROUS2.9 mg/dlSODIUM141 mmol/LPOTASSIUM3.1 mmol/L.CHLORIDE103 mmol/LABG 23-05-2024 07:50:AM PH7.33PCO220.1PO273.2HCO310.5St.HCO313.9BEB-13.6BEecf-14.2TCO222.1O2 Sat94.4O2 Count13.9ABG 23-05-2024 01:31:PM PH6.97PCO224.9PO2223HCO35.5St.HCO36.9BEB-24.3BEecf-23.7TCO213.2O2 Sat95.0O2 Count10.8


Treatment Given(Enter only Generic Name)

1.FLUID AND SALT RESTRICTION

2.INJ. MEROPENEM 500MG IV/BD

3.INJ. DOXY 100MG IV/BD

4.INJ. EPO 4000IU SC/WEEKLY ONCE

5.INJ. LASIX 40MG IV/BD

6.INJ.PAN 40MG IV/OD

7.INJ. OPTINEURON 1AMPOULE IN 100ML NS

8.TAB. THYRONORM 25MCGRT/OD-6AM

9.TAB. SHELCAL -CT RT/OD

10.TAB. OROFER-XT RT/OD

11.TAB.PCM 650MG RT/SOS

12.TAB.NICARDIA 10MG RT/BD

Advice at Discharge

LAMA NOTES

PATIENT ATTENDERS HAVE BEEN EXPLAINED ABOUT PATIENTS CONDITION , THAT IS SEPTIC ENCEPHALOPATHY , ON MECHANICAL VENTILATION , POST CPR STATUS , K/C/O HTN AND HYPOTHYROIDISM HAS BEEN EXPLAINED ABOUT THE FURTHER PLAN OF TREATMENT AND PROGNOSIS ASSOCIATED AND ALL THE RISKS INCLUDING DEATH IN THEIR OWN UNDERSTANDABLE LANGUAGE. BUT THEY ARE NOT WILLING FOR FURTHER STAY AND WANT TO LEAVE AGAINST MEDICAL ADVISE DESPITE EXPLAINING THE POOR PROGNOSIS POST DISCHARGE . HOSPITAL DOCTORS AND NURSING STAFF ARE NOT RESPONSIBLE FOR ANY UNTOWARD EVENTS.



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