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:
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
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