feverprojr LEPTO 43/M

 leptospirosis : 

date of admission 29/9/2022

date of discharge 7/10/2022



Diagnosis

SEPSIS WITH MODS ? VIRAL ETIOLOGY

[AKI , ACUTE LUNG INJURY , ACUTE LIVER INJURY]

GRADE-I HEPATIC ENCEPHALOPATHY (RESOLVED)

S/P 4 SESSIONS HEMODIALYSIS (30/09/22 , 1/10/22 , 3/10/22 , 6/10/22)

Case History and Clinical Findings

42 YEAR OLD MALE PATIENT CAME TO CASUALITY WITH

CHEIF COMPAINTS :

FEVER SINCE 6 DAYS VOMITING SINCE 4 DAYS ( ON AND OFF) SOB SINCE 2 DAYS YELLOWISH DISCOLOURATION OF BODY, URINE SINCE 1 DAYS

HOPI :

patient was apparently asymptomatic 6 days bcak then he developed fever which is high grade not associated with chills and rigors

vomitings 2 days ago 1 episode with food as content, non projectile , non bilious , non blood stained

SOB - since 2 days

yellowish discolouration of body , urine generalised sever myalgia

pedal edema since 1 days

no discolouration or clay coloured stool


no burning micturation ,painabdomen, lose stools, nausea, cough , rashes

PAST HISTORY -

Not a k/c/o DM. HTN, CVA,CAD

FAMILY HISTORY

no significant

PERSONAL HISTORY

DIET-MIXED

APPETITE- NORMAL

SLEEP- INADEQUATE

BOWEL AND BLADDER MOVEMENTS REGULAR

HABITS- ALCOHOL ( OCCASIONAL )

GENERAL EXAMINATION

patient is conscious coherent cooperative well oriented to time place person

moderately built and moderatlely nourished

pallor- present

icterus- presnt

cyanosis - absent

lymphadenopathy- absent

edema - present

VITALS

BP - 100/80 MM HG

PR- 98 BPM

RR- 16 CPM

GRBS - 99

TEMP- 99

SYSTEMIC EXAMINATION

CVS S1 S2 +

RS BAE + , decresed breath sounds right side I ISA, IAA

P/A soft ,non tender, bowel sounds heard

CNS - NFND

COURSE IN THE HOSPITAL:


42/MALE ADMITTED WITH THE ABOVE COMPLAINTS AND WAS EVALUATED FOR THE SAME.PROVISIONALLY DIAGNOSED AS SEPSIS WITH MODS ? LEPTOSPIRA / VIRAL ETIOLOGY [AKI , ACUTE LUNG INJURY , ACUTE LIVER INJURY].STARTED ON IV ANTIBIOTICS,IV FLUIDS,DIURETICS &OTHER SUPPORTIVE CARE.HEMODIALYSIS WAS INITIATED IN V/O DERANGED RFT,ANURIA &METABOLIC ACIDOSIS.DURING HIS HOSPITAL STAY 4 SESSIONS OF HD WERE DONE AND OTHER SUPPORTIVE CARE WAS GIVEN.PATIENT IMPROVED SYMPTOMATICALLY AND WAS DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION WITH THE FOLLOWING ADVISE.
Investigation
USG :-
-RT MILD PLEURAL EFFUSION
-B/L RAISED ECHOGENICITES OF KIDNEYS
-GB WALL EDEMA
-MODERATE ASCITIES
2 D ECHO :- NO RWMA
-MODERATE MR/TR WITH PAH
-EF 60%,GOOD LV SYSTOLIC FUNCTION
-NO DIASTOLIC DYSFUNCTION
-IVC 1.76CMS DILATED NON COLLAPSING
-DILATED RA/ RV /LA/ IVCRFT 02-10-2022 05:06:AM UREA108 mg/dlCREATININE4.6 mg/dlURIC ACID5.6 mg/dlCALCIUM12.2 mg/dlPHOSPHOROUS6.2 mg/dlSODIUM133 mEq/LPOTASSIUM3.5 mEq/LCHLORIDE
97 mEq/L

LIVER FUNCTION TEST (LFT) 02-10-2022 09:06:AM Total Bilurubin12.50 mg/dlDirect Bilurubin10.12 mg/dlSGOT(AST)26 IU/LSGPT(ALT)25 IU/LALKALINE PHOSPHATE555 IU/LTOTAL PROTEINS5.2 gm/dlALBUMIN3.5 gm/dlA/G RATIO2.0ABG 02-10-2022 10:40:PM PH7.35PCO227.7PO287.8HCO314.9St.HCO316.9BEB-9.3BEecf-9.6TCO232.0O2 Sat96.0O2 Count11.4LIVER FUNCTION TEST (LFT) 03-10-2022 05:01:AM Total Bilurubin13.06 mg/dlDirect Bilurubin10.77 mg/dlSGOT(AST)27 IU/LSGPT(ALT)23 IU/LALKALINE PHOSPHATE587 IU/LTOTAL PROTEINS5.1 gm/dlALBUMIN2.2 gm/dlA/G RATIO0.78ABG 03-10-2022 10:41:PM PH7.46PCO231.4PO283HCO322.2St.HCO324.0BEB-0.5BEecf-1.1TCO244.6O2 Sat95.3O2 Count15.8LIVER FUNCTION TEST (LFT) 03-10-2022 10:41:PM Total Bilurubin11.48 mg/dlDirect Bilurubin8.71 mg/dlSGOT(AST)37 IU/LSGPT(ALT)28 IU/LALKALINE PHOSPHATE683 IU/LTOTAL PROTEINS6.0 gm/dlALBUMIN2.6 gm/dlA/G RATIO0.79RFT 03-10-2022 10:41:PM UREA98 mg/dlCREATININE3.5 mg/dlURIC ACID5.1 mg/dlCALCIUM10.0 mg/dlPHOSPHOROUS7.2 mg/dlSODIUM141 mEq/LPOTASSIUM3.3 mEq/LCHLORIDE104 mEq/LABG 05-10-2022 03:55:AM PH7.42PCO238.6PO2122HCO324.7St.HCO325.2BEB0.9BEecf0.8TCO249.8O2 Sat97.1O2 Count16.7LIVER FUNCTION TEST (LFT) 05-10-2022 03:55:AM Total Bilurubin7.91 mg/dlDirect Bilurubin5.66 mg/dlSGOT(AST)30 IU/LSGPT(ALT)25 IU/LALKALINE PHOSPHATE603 IU/LTOTAL PROTEINS6.1 gm/dlALBUMIN2.6 gm/dlA/G RATIO

0.77

RFT 06-10-2022 05:50:AM UREA171 mg/dlCREATININE4.1 mg/dlURIC ACID8.2 mg/dlCALCIUM10.0 mg/dlPHOSPHOROUS7.9 mg/dlSODIUM140 mEq/LPOTASSIUM3.9 mEq/LCHLORIDE98 mEq/LABG 06-10-2022 11:08:PM PH7.43PCO245.1PO249.1HCO329.8St.HCO328.8BEB5.2BEecf5.6TCO259.6O2 Sat82.1O2 Count14.6LIVER FUNCTION TEST (LFT) 06-10-2022 11:08:PM Total Bilurubin3.55 mg/dlDirect Bilurubin2.54 mg/dlSGOT(AST)30 IU/LSGPT(ALT)25 IU/LALKALINE PHOSPHATE599 IU/LTOTAL PROTEINS6.9 gm/dlALBUMIN3.0 gm/dlA/G RATIO0.77RFT 06-10-2022 11:08:PM UREA98 mg/dlCREATININE2.4 mg/dlURIC ACID5.0 mg/dlCALCIUM10.0 mg/dlPHOSPHOROUS6.1 mg/dlSODIUM136 mEq/LPOTASSIUM3.9 mEq/LCHLORIDE100 mEq/LTreatment Given(Enter only Generic Name)

Treatment Given(Enter only Generic Name)

1) FLUID RESTRICTION <1.5 LIT /DAY

2) SALT RESTRICTION <2 GM/ DAY

3) INJ . PIPTAZ 2.25 GM/ IV/TID

4) INJ DOXY 100 MG /IV/BD

5)INJ PAN 40MG /IV /OD/BBF

6) INJ ZOFER 4MG/IV/SOS

7) INJ LASIX 40 MG /IV/BD

8)IV FLUDS I UNIT NS, 1 UNIT RL AT 50 ML/HR


9) INJ THIAMINE 200 MG IN 100 ML NS/IV/BD

10) INJ NEOMOL 1GM/IV/SOS IF TEMP >101F , DO NOT GIVE >2GM/DAY

11) INJ OPTINEURON 1AMP IN 100 ML NS IV OD

12) TAB UDILIV 300 MG /PO/BD

13) TAB RIFAGUT 550 MG PO/BD

14) TAB ULTRACET 1/2 TAB /PO/QID

15) TAB ALDACTONE 25 MG/PO/OD

16) SYP LACTULOSE 15 ML /PO/BD

17) SYP POTKLOR 10 ML IN 1 GLASS OF WATER PO/BD

18)STRICT I/O CHARTING

19)TEMP , GRBS CHARTING

20) BP,PR,RR,SPO2 MONITORING 2ND HOURLY

21) NEB WITH DUOLIN 8TH HOURLY

BUDECORT -12TH HOURLY

22) 3-4 EGG WHITES/ DAYS

23) PROTEIN POWDER 3-4 SCOOPS IN 1 GLASS MILK /TID

24)ORS SACHETS ( 4 SACHETS IN 1LITER WATER ) 200 ML TO GIVE AFTER EVERY EPISODE OF LOOSE STOOL

COURSE IN THE HOSPITAL:

42/MALE ADMITTED WITH THE ABOVE COMPLAINTS AND WAS EVALUATED FOR THE SAME.PROVISIONALLY DIAGNOSED AS SEPSIS WITH MODS ? LEPTOSPIRA / VIRAL ETIOLOGY [AKI , ACUTE LUNG INJURY , ACUTE LIVER INJURY].STARTED ON IV ANTIBIOTICS,IV FLUIDS,DIURETICS &OTHER SUPPORTIVE CARE.NEPHROLOGY CONSULTATION WAS DONE AND ADVISE FOLLOWED.HEMODIALYSIS WAS INITIATED IN V/O DERANGED RFT,ANURIA &METABOLIC ACIDOSIS.DURING HIS HOSPITAL STAY 4 SESSIONS OF HD WERE DONE AND OTHER SUPPORTIVE CARE WAS GIVEN.PATIENT IMPROVED SYMPTOMATICALLY AND WAS DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION WITH THE FOLLOWING ADVISE.

Advice at Discharge

1) FLUID RESTRICTION <1.5 LIT /DAY

2) SALT RESTRICTION <2 GM/ DAY

3) TAB PAN 40MG /PO/OD/BBF

4) TAB LASIX 20 MG PO/BD

5) TAB ALDACTONE 25 MG PO/OD

6) TAB BENFOMET PLUS PO/OD


) TAB UDILIV 300 MG /PO/BD
8) TAB RIFAGUT 550 MG PO/BD
9) TAB ULTRACET 1/2 TAB /PO/QID
10) SYP LACTULOSE 15 ML /PO/BD
11) 3-4 EGG WHITES/ DAYS
12) PROTEIN POWDER 3-4 SCOOPS IN 1 GLASS MILK /TID
13)ORS SACHETS ( 4 SACHETS IN 1LITER WATER ) DRINK 200 ML AFTER EVERY EPISODE OF LOOSE STOOL



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