feverprojr LEPTO 43/M 202254447

 leptospirosis - 20221246172

Diagnosis

SIRS WITH MODS-[THROMBOCYTOPENIA (RESOLVED ),ALI ( RESOLVED ),,AKI (PRE-RENAL) ( RESOLVED ) ] SECONDARY TO ? LEPTOSPIROSIS(WEILS DISEASE)

DYSELECTROLYTEMIA {HYPOKALEMIA(RESOLVED),HYPONATREMIA(RESOLVED) - SIADH} , DCMP ( RESOLVED ) ALCOHOL INDUCED WET BERI BERI

Case History and Clinical Findings

A 42 YEAR OLD MALE PRESENTED WITH COMPLAINTS ,

ABDOMINAL PAIN SINCE 4 DAYS

VOMITINGS SINCE 4 DAYS

DECREASED URINE OUTPUT SINCE 3 DAYS

CONSTIPATION SINCE 3 DAYS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC SINCE 4 DAYS BACK THEN HE COMPLAINED OF ABDOMINAL PAIN WHICH IS DIFFUSE ASSOCIATED WITH VOMITINGS WHICH IS BILIOUS,NON-PROJECTILE,GREENISH IN COLOR ASSOCIATED WITH CONSTIPATION(PASSED STOOLS 3 DAYS BACK).PATIENT ALSO COMPLAINED OF DECREASED URINE OUTPUT SINCE 3 DAYS.

THERE IS A HISTORY OF CONTINUOUS ALCOHOL CONSUMPTION WITHOUT FOOD INTAKE SINCE 10 DAYS.

COURSE IN HOSPITAL :PATIENT CAME TO HOSPITAL WITH C/O VOMITINGS SINCE 3 DAYS , DECREASED URINE OUTPUT AND ABDOMINAL PAIN SINCE 3DAYS , CONTINUOUS ALCOHOL CONSUMPTION SINCE 3 DAYS.

N/K/C/O HTN , DM , EPILEPSY, ASTHMA , CAD , CVA

HIS HEMOGRAM SHOWS REDUCED HEMOGLOBIN , LEUCOCYTOSIS , THROMBOCYTOPENIA . HIS LFT AND RFT WERE DERANGED . HE HAD DYSELECTROLYTEMIA . TO CORRECT HYPOKALEMIA HE WAS GIVEN 40 MEQ OF KCL AND 3 % NS RESPECTIVELY ON 29/12/2022 . HE WAS GIVEN IV FLUIDS ADEQUATELY , CONTINUED ON SYP . POTKLOR 15 ML TID , 3 5 NS @ 75 / HR . PATIENT WAS DISCHARGED AFTER CORRECTING ALL THESE CONDITIONS IN HEMODYNAMICALLY STABLE CONDITIONS.

REFERRALS:

SURGERY OPINION WAS TAKEN ON 30/12/2022 I/V/O RIGID ABDOMEN AND DECREASED STOOL PASSAGE , ADVISE FOLLOWED

GASTROENTEROLOGIST OPINION WAS TAKEN ON 30/12/2022 I/V/O VOMITINGS , LOSS OF APPETITE , JAUNDICE , DISTENDED ABDOMEN SINCE 3 DAYS , WAS ADVISED FOR SERUM LIPASE , SERUM AMYLASE , AND CT ABDOMEN PLAIN , ADVISE FOLLOWED

NEPHROLOGIST OPINION WAS TAKEN ON 30/12/2022 I/V/O REDUCED URINE OUTPUT SINCE 3 DAYS , ADVISE FOLLOWED

PYSCHIATRY REFERRAL WAS TAKEN ON 30/12/2022 , I/V/O PATIENT'S BINGE ALCOHOL CONSUMTION SINCE 5 DAYS , .PATIENT PSYCHOEDUCATED, BRIEF COUNSELLING GIVEN EXPLAINING HARMFUL EFFECTS OF ALCOHOL,TOBACCO , ADVISE FOLLOWED

PSYCHIATRY REFERAL REPEATED ON 2/1/2023 , PATIENT WAS COUNSELLED AND REASSURED , ADVISE FOLLOWED

PERSONAL HISTORY:

APPETITE:DECREASED SINCE 10 DAYS

DIET:MIXED

SLEEP:ADEQUATE

BOWEL HABITS:IRREGULAR

BLADDER HABITS:REGULAR

ADDICTIONS:H/O ALCOHOL INTAKE SINCE 30 YEARS(SARA)

ON EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,CO-OPERATIVE.

ICTERUS PRESENT ,B/L PEDAL EDEMA PRESENT PITTING TYPE UPTO ANKLES.

VITALS:

TEMP:AFEBRILE

BP:100/80 MMHG

PULSE RATE:84 BEATS/MIN

RESPIRATORY RATE:16 CYCLES/MIN

SPO2:99% @RA

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:S1S2 +

RESPIRATORY SYSTEM:BAE+,NVBS

CENTRAL NERVOUS SYSTEM:CONSCIOUS,COHERENT,CO-OPERATIVE.HIGHER MENTAL FUNCTIONS INTACT

PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY.

Investigation

USG ABDOMEN:HEPATOMEGALY ( 18 CMS )

ECG : SHOWS NO ABNORMALITY , HAS NORMAL SINUS RHYTHM

2D ECHO:

28/12/22:

DILATED HEART CHAMBERS ( ALL 4) WITH SCLEROTIC AORTIC VALVE

MODERATE TR+ WITH PAH (ECCENTRIC TR+);MODERATE MR+;MILD AR+

NO RWMA;NO AS/MS.SCLEROTIC AV

FAIR LV FUNCTION

NO DIASTOLIC DYSFUNCTION.NO PE

REVIEW 2D ECHO:

30/12/22

NO RWMA,MILD LVH (+)

MILD MR(+) ;TRIVIAL TR(+)/AR(+)

SCLEROTIC AV,NO AS/MS

EF=53% ,FAIR LV FUNCTION

NO DIASTOLIC DYSFUNCTION

NO PAH/PE

IVC SIZE(1.10CMS)

R.A SIZE(3.9CMS)

R.V SIZE(3.85CMS)

L.A SIZE(3.78CMS)

CULTURE AND SENSITIVITY:

BLOOD C/S:NO GROWTH AFTER 24 HOURS OF AEROBIC INCUBATION

URINE C/S;NO GROWTH

HEMOGRAM ON :

31/12/2022 : HB : 12.2 , TLC : 20700, PLATELET : 1.30 LAKHS /CU MM

1/1/2023 : HB : 11.9 GM /DL , TC : 169000 CELLS / CUMM , NEU : 74 , LYM : 14 , PCV : 33.2 , MCHC : 35.8 , PLATELET : 1.72

2/1/2023 : HB : 11.4 GM / DL , TC : 13100 CELLS / CUMM , NEU : 75 , LYMPH : 11 , PCV : 32.9 , MCV : 91.4 , MCHC : 34.7 , RDW - CV : 14.7 RBC : 3.6 MILLIONS / CU MM

3/1/2023 : Hb : 11.7 GM /DL , TC : 15100 , NEU : 73, LYMPHOCYTES : 14, MONO : 09, EOS : 04, PCV 34.3 , MCV ; 91.7 , MCH : 31.3 , MCHC : 34.1 , RBC : 3.74 MILLIONS / CU MM

5/1/23 : hb : 11.9 , TC : 14000 , NEU : 67 , LYM : 20 , EOS : 04 , MONO ; 09 , BASO : 00 , PCV : 35.7 , MCV : 87 .1 , MCH : 29.0 , MCHC : 33.3 , RBC 4.1 MIILIONS / CC , PLC : 1.20 LAKHS / CU MM

Treatment Given(Enter only Generic Name)

IVF 2 UNITS NS,11 UNIT RL @75ML/HR

INJ.MEROPENEM 500MG IV/BD(1-X-1)X5 DAYS

INJ.DOXY 100MG IV/BD(1-X-1)X7 DAYS

INJ.PAN 40MG IV/OD(1-X-X)

INJ.OPTINEURON 1AMP IN 100ML NS IV/OD(X-1-X)

INJ.THIAMINE 200MG IN 100ML NS IV/BD(1-X-1)

TAB.DOLO 650MG PO/BD(1-X-1)

INJ.VITAMIN K 100MG IV/OD(1-X-X)X3 DAYS

TAB.UDILIV 300MG PO/BD(1-X-1)

TAB.VIBOLIV 500MG PO/BD(1-X-1)

SYP.HEPAMERZ 10ML PO/TIID(1-1-1)

SYP.POTKLOR 15ML PO/TID(1-1-1)

SYP.LACTULOSE 15ML PO/TID(1-1-1)

DULCOLAX SUPPLEMENTS SOS

TAB.LORAZEPAM 1 MG PO/SOS IF DISTURBED SLEEP

INJ.KCL 40MEQ IN 500ML NSX2 DAYS IV/STAT

Advice at Discharge

1. TAB. TOLVAPTAN 30 MG PO / OD X 3 DAYS 1--X--X

2. SYP.LACTULOSE 15 ML PO/HS X 1 DAY X--X--1

3. TAB . BENFOMET PLUS PO/OD 1--X--X

4. ORS SACHETS , 4 SACHETS IN 1 LITRE OF WATER SOS