A 25 yr old male with sob
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UNIT 1 ADMISSION
Dr k vaishnavi( pgy3)
Dr nikhitha( pgy3)
Dr raveen( pgy1)
ICU BED 4
A 25 yr old male , factor worker came to casuality with complaints of fever since 3 days , vomitings since 2 days ,loose sto
ols since today, cough since 2 days, grade 4 sob since evening, chest pain , lower back pain, abdominal pain since evening
Pt was apparently asymptomatic 3 days ago then he devwloped high grade fever, continuous, associated with chills and rigor
Vomitings since 2 days 4 to 5 episodes water in consistency, non blood tinged associated with nausea occurs immediately after food intake
Cough since 2 days with scanty sputum white color
Loose stools since today 3 episodes ,watery in consistency associated with diffuse pain abdomen
No history of decreased urine output, burning micturition, chest pain , lower back pain since evening
Grade 4 sob since evening( 8 pm)
No h/ o orthopnea, pnd, pedal edema
Past history:
Not ak/c/o hypertension, diabetes mellitus, tuberculosis, asthma, coronary artery disease
Not received covid vaccination
Personal history:
He is not married, factory worker by occupation, with mixed diet , normal appetite,
regular bowel, bladder habits non alcoholic , non smoker
Family history : not significant
General examination:
Pt c/ c/ c
Vitals:
Bp- 100/60mmhg
Pr-184 bpm regular
Rr-46cpm
Temperature-105 degress
Spo2- 94-96% on ra.
Ecg monitor showing Psvt.
Immediately carotid sinus massage was done .
1) INJ NEOMAL 1G IV STAT
2) INJ TRAMADOL 1 AMP in 100 ML NS IV given as pt was complaining of low back ache and generalised body aches
3) COLD ICE PACKS WERE PLACED.
4)IVF 3 unitd NS bolus given.
5) INJ CEFTRIAXONE 1 G IV BD.
After 10 min rate reduced and rythm was normal.
BP-80/60 mmhg
PR - 120 bpm ,regular.
Rr-40/min.
ABG showing
PH- 7.419
Pco2- 24.2
Po2- 92.2
Spo2- 93.6
Hco3- 15.4
Pt is on norad 6 ml/ hr
Systemic examination
Cvs- s1, s2 heard
Rs- bAE+, NVBS
P/A - soft , tendernesa in right hypochondriac region
Cns- intact
Provisional diagnosis :psvt
Pancytopenia under evaluation, fever under evaluation- ? Acute gastroenteritis(typhoid fever/? leptospira/ ? Viral pyrexia ? Pre renal AKI
ECG at the time of admission
Investigations on 27/9/21
Hemogram:
Hb- 8.9
Tlc- 2,100
Plt- 37,000
Rbc- 3.82
Pcv- 26
Mcv- 68.1
Mch- 23.3
Mchc- 34.2
Serum urea- 89
Serum creatinine- 2.1
Na+ 128
K+ 3
Cl- 101
Lft
Tb-0.89
Db-0.17
Ast- 34
Alt- 26
Alp- 110
Alb- 2.29
A/G- 1.34
Serology -negative
Rapid dengue- negative
Hemogram on 27/09/21 mrng sample
Hb- 8.9
Tlc- 3,500
Rbc- 3.82
Plt- 65000
Esr-80
Recticulocyte count- 0.5
Serum k+ 4.5
Serum electrolytes
Na+ 128
Cl- 101
Serum mg+2 1.8
Serum urea- 89
Serum creatinine- 2.1
Serum LDH- 365
On 28/09/21
Hb- 10.6
Tlc- 7,100
Plt- 66,000
Rbc- 4.55
Serum urea- 65
Serum creatinine- 1.6
Na+ 132
K+ 3.9
Cl- 102
On 29/09/21
Hb- 10.8
Tlc-7,400
Rbc- 4.68
Plt- 80,000
Soap notes
Icu bed- 4
Day 3
S- Patient is comfortably sleeping on his bed. He says his dyspnea and cough have reduced comparatively.
O-
pt is c/c/c
Vitals:
Bp- 100/70 mmhg
Pr- 91 bpm regular , normal volume
Temperature- 99.6F
Grbs- 109mg
I/0-2100/1400
cvs- s1,s2 + no murmur
Rs- nvbs+ wheeze in ISA
P/A- soft , tenderness in rt hypochondriac, bs+
A- HFr EF with EF- 35% secondary to severe PAH( RVSP=68 mmhg) ? Viral myocarditis with pancytopenia under evaluation secondaey to ? Typhoid ? Viral with pre renal AKI
P-
1) Fluid restriction < 1.5 l/ day
2) Salt restriction< 2.5 gm / day
3) INJ LASIX 20 mg / IV/ BD
4) INJ MONOCEF 1gm / IV/ BD
5) T. DOXY 100 PO/ / BD
6) INJ OPTINEURON 1amp in 100 ml/ NS IV/ OD
7)INJ NORAD- DS@5ml/ hr
8) T. PCM 650 mg/ po/ TID
9) INJ ZOFER 4mg / IV /BD
10) INJ NEOMOL100 ml/ IV/ SOS
11) T .ULTRACET PO/ SOS
12) T ATORVAS 20 mg po/ hs
13) monitor vitals temp, bp hrly
14) strict I/0 charting
15 ) GRBS- 12 th hrly
Soap notes
Icu bed- 3
Day 4
S- Patient is comfortably sleeping on his bed. He says no dysnea, no cough decreased pain abdomen
O-
pt is c/c/c
Vitals:
Bp- 100/80 mmhg @ 1ml / hr norad
Pr- 88 bpm regular , normal volume
Temperature- 98.6F
Grbs- 99mg
I/o -900/1500
cvs- s1,s2 + no murmur
Rs- bae+ nvbs+
P/A- soft , bs+
A- HFr EF with EF- 35% secondary to severe PAH( RVSP=68 mmhg) ? Viral myocarditis with pancytopenia under evaluation secondaey to ? Typhoid ? Viral with pre renal AKI
P-
1) Fluid restriction < 1.5 l/ day
2) Salt restriction< 2.5 gm / day
3) INJ LASIX 20 mg / IV/ BD
4) INJ MONOCEF 1gm / IV/ BD
5) T. DOXY 100 PO/ / BD
6) INJ OPTINEURON 1amp in 100 ml/ NS IV/ OD
7)INJ NORAD- DS@1ml/ hr
8) INJ ZOFER 4mg / IV /BD
9) T .ULTRACET PO/ SOS
10) T.PCM 650 mg PO/ SOS
12) monitor vitals temp, bp hrly
13) strict I/0 charting
14 ) GRBS- 12 th hrly
Soap notes
Ward case
Day 5
S- Patient is comfortably sleeping on his bed. He says no dysnea, no cough decreased pain abdomen
O-
pt is c/c/c
Vitals:
Bp- 110/70 mmhg
Pr- 76 bpm regular , normal volume
Temperature- 98.6 F
cvs- s1,s2 + no murmur
Rs- bae+ nvbs+
P/A- soft , bs+
A- cardiogenic shock ( resolved)
HFr EF with EF - 46% severe PAH secondary to ? Viral myocarditis/ ? Typhoid fever
Pancytopenia secondary to infectious etiology
Pre renal AKI
PSVT - resolved
P-
1) Fluid restriction < 1.5 l/ day
2) Salt restriction< 2.5 gm / day
3) INJ LASIX 20 mg / IV/ BD
4) INJ MONOCEF 1gm / IV/ BD
5) T. DOXY 100 PO/ / BD
6) INJ OPTINEURON 1amp in 100 ml/ NS IV/ OD
7)INJ ZOFER 4mg / IV /BD
8)T.PCM 650 mg PO/ SOS
9)INJ PAN 40 mg IV/ OD
10) monitor vitals temp, bp hrly
Treatment given
Day 1
1) Fluid restriction < 1.5 l/ day
2) Salt restriction< 2.5 gm / day
3) INJ LASIX 20 mg / IV/ BD
4) INJ MONOCEF 1gm / IV/ BD
5) T. DOXY 100 PO/ / BD
6) INJ OPTINEURON 1amp in 100 ml/ NS IV/ OD
7)INJ NORAD- DS@5ml/ hr
8) T. PCM 650 mg/ po/ TID
9) INJ ZOFER 4mg / IV /BD
10) INJ NEOMOL100 ml/ IV/ SOS
11) T .ULTRACET PO/ SOS
12) T ATORVAS 20 mg po/ hs
13) monitor vitals temp, bp hrly
14) strict I/0 charting
15 ) GRBS- 12 th hrly
Day 2
1) Fluid restriction < 1.5 l/ day
2) Salt restriction< 2.5 gm / day
3) INJ LASIX 20 mg / IV/ BD
4) INJ MONOCEF 1gm / IV/ BD
5) T. DOXY 100 PO/ / BD
6) INJ OPTINEURON 1amp in 100 ml/ NS IV/ OD
7)INJ NORAD- DS@5ml/ hr
8) T. PCM 650 mg/ po/ TID
9) INJ ZOFER 4mg / IV /BD
10) INJ NEOMOL100 ml/ IV/ SOS
11) T .ULTRACET PO/ SOS
12) T ATORVAS 20 mg po/ hs
13) monitor vitals temp, bp hrly
14) strict I/0 charting
15 ) GRBS- 12 th hrly
Day 3
1) Fluid restriction < 1.5 l/ day
2) Salt restriction< 2.5 gm / day
3) INJ LASIX 20 mg / IV/ BD
4) INJ MONOCEF 1gm / IV/ BD
5) T. DOXY 100 PO/ / BD
6) INJ OPTINEURON 1amp in 100 ml/ NS IV/ OD
7)INJ ZOFER 4mg / IV /BD
8)T.PCM 650 mg PO/ SOS
9)INJ PAN 40 mg IV/ OD
10) monitor vitals temp, bp hrly
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