A 45 year old male with HFPEF 2° to Alcoholism - wet beri beri,Acute infarct in PCA territory (Recurrent CVA),Acute hepatitis 2° to viral with CLD(resolving) AKI( Renal interstitial nephritis) ?Uremic Encephalopathy,Delirium with Alcohol dependence syndrome,chronic alcoholic and smoker,k/c/o HTN since 5months
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.
A 45 yr old male patient who is auto driver by occupation came with
C/o weakness of b/l upperlimb and lowerlimb since 1 week
C/o pedal edema since 1 week
HOPI:
Pt was apparently asymptomatic 1 week back then developed weakness of b/l upper and lower limb since then
No h/o deviation of mouth ,giddiness,decreased urine output ,burning micturition ,facial puffiness
C/o swelling of b/l lower limbs upto knees which is pitting type
H/o sob present
H/o palpitations present on exertion
No h/o fever ,cold ,cough
Past history:
K/c/o HTN since 5 months and on
tab metaprolol 50mg od
Tab hydroxychloroquine 12.5mg od
Not k/c/o Epilepsy ,CAD,Asthma,DM
Personal history:
Patient takes mixed diet, appetite normal,sleep adequate,bowel and bladder regular,chronic alcoholic since 20 years and takes 90-180ml/day,smoker
General examination:
Pt is drowsy,conscious
No pallor
No icterus
No cyanosis
No clubbing
No koilonychia
No lymphadenopathy
B/l pedal edema + upto knees which is pitting type
Vitals- Temperature- Afebrile on touch
PR- 79bpm
RR- 18cpm
BP- 180/110mmhg
Systemic examination:
CVS- S1S2 heard , no murmurs
RS- BAE present ,NVBS +
P/A - distended,no tenderness,no organomegaly,bs+
CNS- level of consciousness- drowsy
Cranial nerves- normal
Sensory system - not elicitable
Power- normal
Tone - normal
Reflexes B T S K A P
R- 2+ 2 + 1+ 2+ 1+ extension
L - 2+ 2+ 1+ 2+ 1+ extension
Investigations-
Cbp:
Hb- 7.5
Tlc-13000
Plt-1.5 lakhs
BGT- 0+ve
Pt- 25sec
INR- 1.8
APTT- 49sec
BT- 2mins 30sec
CT- 5mins 30sec
Rbs-114
Serology- Negative
LFT-
Tb-1.35
DB- 0.31
Ast- 1265
Alt- 1615
Alp-470
TP-5.5
Alb-3.4
A/G - 1.66
RFT-
Urea- 180
Cr-5.5
Uric acid-13.0
Ca2+ -9.2
Phosphorus- 6.4
Na+ - 131
K+ - 4.5
Cl - 103
Spot urine protein -15
Spot urine crratinine- 19.2
Ratio - 0.78
Abg :
PH - 7.39
Pco2- 16.7
Pco2- 108
Hco3- - 13.6
Cue:
Alb-1+
Pus cells- 10-12
Epithelial cells- 4-5
Sugars- nil
USG:
ECG-
Treatment:
IVF - NS,RL @100ml/hr
Tab.Ecospirin 75mg/po/od
Tab.Clopidogrel 75mg/po/od
Tab.Atorvastatin 40mg/po/od
Salt restricted diet <2.4g/day
Inj.Lasix 20mg/iv/bd
Tab.Benfomet 20mg/po/od
Bp charting 2nd hrly
Strict I/O charting hrly
Temperature charting 4th hrly
Tab.Nicardia 10mg/po/stat
Syp.Lactulose 15ml/po/bd
Syp.Hepamerz 15ml/po/bd
Inj.monocef 1g/iv/bd
Tab.Azithromycin500mg/po/od
DAY2:
No fresh complaints
O/E- pt is drowsy , oriented to person ,not oriented to time ,place
No Pallor
Icterus present
No Cyanosis
No Clubbing
No koilonychia
No Lymphadenopathy
B/L pitting type pedal edema upto knees +
Temperature - Afebrile
PR- 102bpm
BP- 150/100mmhg
GRBS - 160mg/dl
I/O - 2000/1800 ml
CVS - S1S2 + ,JVP raised
RS - BAE+
P/A - Soft,non tender,bs sluggish
CNS -Pupils - B/L reacting to light
Reflexes - B T S K A P
R 3+ 2+ 1+ 2+ 1+ extension
L 2+ 2+ 1+ 2+ 1+ extension
Reffered to Psychiatry i/v/o altered sensorium,hallucinations,self talk and chronic alcoholic since 20years
Investigations:
CBP-
CUE-
2D Echo-
Reticulocyte count -
Treatment:
IVF - NS,RL with thiamine 2amp(slow iv) u.o+35ml/hr
Tab.Ecospirin 75mg/po/od
Tab.Clopidogrel 75mg/po/od
Tab.Atorvastatin 40mg/po/od
Salt restricted diet <2.4g/day
Inj.Lasix 40mg iv/bd
Tab.Benfomet 20mg/po/od
Bp charting 2nd hrly
Strict I/O charting hrly
Temperature charting 4th hrly
Syp.Lactulose 15ml/po/bd
Syp.Hepamerz 15ml/po/bd
Inj.monocef 1g/iv/bd
Tab.Azithromycin500mg/po/od
Inform sos
Inj.vit k 10mg/iv/stat
Ducolex suppositories (2tab)
Tab.pregabalin 75mg
Inj.lorazepam 4mg (1amp/im/hs)if pt is not getting sleep after taking pregabalin
Inj.lorazepam 4mg(1amp/im/sos)if pt is iiritable
DAY3:
No fresh complaints
O/E- pt is conscious,drowsy , oriented to person ,not oriented to time ,place
Icterus present
B/L pitting type pedal edema upto knees +
Temperature - febrile to touch
PR- 87bpm
RR - 17cpm
BP- 180/110mmhg
Spo2- 97%@R.A
GRBS - 143mg/dl
I/O - 2000/1800 ml
CVS - S1S2 +
RS - BAE+
P/A - Soft,non tender,bs sluggish
CNS -pupils - B/L reacting to light
Reflexes - B T S K A P
R 3+ 2+ 1+ 3+ 1+ -
L 2+ 2+ 1+ 2+ 1+ -
Investigations:
CBP-
CUE-
PT-
APTT-
Reticulocyte count -
Treatment:
IVF - NS,RL @u.o+30ml/hr
Inj.Thiamine 2amp in 100ml NS/ IV /BD
Tab.Aldactone 50mg/po/bd
Tab.Ecospirin (75/20mg)/po/hs
Tab.Clopidogrel 75mg/po/od
Tab.Atorvastatin 20mg/po/od
Tab.Cilnidipine 10mg/po/od
Salt restricted diet <2.4g/day
Inj.Lasix 20mg iv/bd
Bp charting 2nd hrly
Strict I/O charting hrly
Temperature /PR/Spo2charting 4th hrly
Syp.Lactulose 15ml/po/bd
Syp.Potchlor 15ml in 1 glass of water/po/bd
Syp.Hepamerz 15ml/po/od
Inj.monocef 1g/iv/bd
Tab.Azithromycin500mg/po/od
Tab.pregabalin 75mg
Inj.lorazepam 4mg (1amp/im/hs)if pt is not getting sleep after taking pregabalin
Inj.lorazepam 4mg(1amp/im/sos)if pt is iiritable
DAY4:
No fresh complaints
O/E- pt is conscious,drowsy , not oriented to time ,place,person
No fever spikes
B/L pitting type pedal edema upto knees +
Temperature - Afebrile
PR- 99bpm
RR - 17cpm
BP- 150/90mmhg
GRBS - 158mg/dl
Spo2- 96%@R.A
I/O - 2850/1750 ml
CVS - S1S2 +,JVP raised
RS - BAE+ , b/l fine crepts + ISA,IAA,MA
P/A - Soft,non tender
CNS- pupils - R -reacting to light
L- not reacting to light
Reflexes - B T S K A P
R 3+ 2+ 1+ 3+ 1+ -
L 2+ 2+ 1+ 2+ 1+ -
Investigations:
CBP-
PT- 15sec
INR-1.11
APTT-30sec
ABG-
RFT-
LDH-
Treatment:
IVF - 1 RL @50ml/hr(slow iv)
Inj.Thiamine 2amp in 100ml NS/ IV /TID
Tab.Aldactone 50mg/po/bd
Tab.Ecospirin (75/20mg) H/S
Tab.Cilnidipine 10mg/po/bd
Salt restricted diet <2g/day
Fluid restriction <2lit/day
Propped up posture
Inj.Lasix 20mg iv/bd
Bp/Spo2-/PR charting 2nd hrly
Strict I/O charting hrly
Syp.Lactulose 15ml/po/hs
Syp.Potchlor 15ml in 1 glass of water/po/tid
Syp.Hepamerz 15ml/po/bd
Inj.monocef 1g/iv/bd
GRBS charting 8th hrly
Tab.pregabalin 75mg
Inj.lorazepam 4mg (1amp/im/hs)if pt is not getting sleep after taking pregabalin
Inj.lorazepam 4mg(1amp/im/sos)if pt is iiritable
DAY 5:
O/E- pt is conscious,not coherent , oriented to person,not oriented to time ,place
Pt passed stools yesterday evening
B/L pitting type pedal edema upto knees +
Temperature - Afebrile
PR- 98bpm
RR - 17cpm
BP- 160/100mmhg
GRBS - 131mg/dl
Spo2- 96%@R.A
I/O - 2350/1300 ml
CVS - S1S2 +
RS - BAE+ , b/l fine crepts + ISA,IAA,MA
P/A - Soft,non tender
CNS- pupils - R -reacting to light
L- not reacting to light
Reflexes - B T S K A P
R 3+ 2+ 1+ 3+ 1+ -
L 2+ 2+ 1+ 2+ 1+ -
Investigations:
CBP-
PT-15sec
APTT-30sec
INR-1.11
RFT-
LDH-
Coombs test-
Treatment:
IVF - 1 RL @50ml/hr(slow iv)
Inj.Thiamine 2amp in 100ml NS/ IV /TID
Tab.Aldactone 50mg/po/bd
Tab.Ecospirin (75/20mg) H/S
Tab.Cilnidipine 10mg/po/bd
Salt restricted diet <2g/day
Fluid restriction <2lit/day
Propped up posture
Inj.Lasix 20mg iv/bd
Bp/Spo2-/PR charting 2nd hrly
Strict I/O charting hrly
Syp.Lactulose 15ml/po/hs
Syp.Potchlor 15ml in 1 glass of water/po/tid
Syp.Hepamerz 15ml/po/bd
Inj.monocef 1g/iv/bd
Temperature charting 4th hrly
Tab.pregabalin 75mg
Inj.lorazepam 4mg im
DAY 6:
O/E- pt is conscious,not coherent ,not oriented to time ,place,person
Pt passed stools
Temperature - Afebrile
PR- 98bpm
RR - 17cpm
BP- 180/90mmhg
GRBS - 126mg/dl
Spo2- 96%@R.A
I/O - 12500/1000 ml
CVS - S1S2 +
RS - BAE+ , b/l fine crepts + ISA,IAA,MA
P/A - Soft,non tender
CNS- pupils - R -reacting to light
L- not reacting to light
Investigations:
CBP-
RFT-
IVF - 1 RL @50ml/hr(slow iv)
Inj.Thiamine 2amp in 100ml NS/ IV /TID
Tab.Aldactone 50mg/po/bd
Tab.Ecospirin (75/20mg) H/S
Tab.Cilnidipine 10mg/po/bd
Salt restricted diet <2g/day
Fluid restriction <2lit/day
Propped up posture
Inj.Lasix 40mg iv/bd
Bp/Spo2-/PR charting 2nd hrly
Strict I/O charting hrly
Syp.Lactulose 15ml/po/bd
Syp.Potchlor 15ml in 1 glass of water/po/tid
Syp.Hepamerz 15ml/po/bd
Inj.monocef 1g/iv/bd
Temperature charting 4th hrly
Tab.Arkamine 0.1mg od
Tab.pregabalin 75mg
Inj.lorazepam 4mg/im
Inj.Haloperidol 5mg im sos
DAY 7:
O/E- pt is drowsy but arousable,not coherent ,not oriented to time ,place,person
Temperature - Afebrile
PR- 82bpm
RR - 17cpm
BP- 150/80mmhg
GRBS - 126mg/dl
GCS-E4V5M6
Spo2- 96%@R.A
I/O - 1630/2800 ml
CVS - S1S2 +
RS - BAE+ ,NVBS
P/A - Soft,non tender
CNS- pupils - NSRL
Investigations:
CBP-
IVF - NS, RL u.o+ 30ml/hr
Inj.Thiamine 2amp in 100ml NS/ IV /TID
Tab.Aldactone 50mg/po/bd
Tab.Ecospirin (75/20mg) H/S
Tab.Cilnidipine 10mg/po/bd
Salt restricted diet <2g/day
Fluid restriction <2lit/day
Propped up posture
Inj.Lasix 40mg iv/bd
Bp/Spo2-/PR charting 2nd hrly
Strict I/O charting hrly
Syp.Lactulose 15ml/po/bd
Syp.Potchlor 15ml in 1 glass of water/po/tid
Syp.Hepamerz 15ml/po/bd
Inj.monocef 1g/iv/bd
Temperature charting 4th hrly
Tab.Arkamine 0.1mg od
Tab.pregabalin 75mg
Inj.lorazepam 2mg IM
Day8:
O/E- pt is drowsy but arousable,not coherent ,not oriented to time ,place,person
Temperature - Afebrile
PR- 82bpm
RR - 17cpm
BP- 180/110mmhg
GCS-E4V5M6,15/15
Spo2- 97%@R.A
I/O - 2000/2300 ml
CVS - S1S2 +
RS - BAE+ ,NVBS
P/A - Soft,non tender
CNS-
Power R L
UL 2/5 2/5
LL 2/5 2/5
Reflexes- B T S A K P
R - - - 2+ 2+ -
L - - - 2+ 2+ -
Investigations:
BGT - O+ve
Treatment:
IVF - NS, RL u.o+ 30ml/hr
Inj.Thiamine 2amp in 100ml NS/ IV /TID
Tab.Aldactone 50mg/po/bd
Tab.Ecospirin (75/75/20mg) H/S
Tab.Cilnidipine 10mg/po/bd
Salt restricted diet <2g/day
Fluid restriction <2lit/day
Propped up posture
Inj.Lasix 40mg iv/bd
Bp/Spo2-/PR/temp charting 4th hrly
Strict I/O charting hrly
Syp.Lactulose 25ml/po/bd
Syp.Potchlor 15ml in 1 glass of water/po/tid
Syp.Hepamerz 15ml/po/bd
Inj.monocef 1g/iv/bd
Tab.Arkamine 0.1mg od
Tab.pregabalin 75mg po
Inj.lorazepam 2mg IM BD
Inj.Haloperidol 5mg/im/sos(if pt is irritable)
Day9:
O/E- pt is drowsy but arousable,not coherent ,not oriented to time ,place,person
Temperature - Afebrile
PR- 84bpm
RR - 18cpm
BP- 160/90mmhg
GCS-E4V5M6,15/15
Spo2- 97%@R.A
I/O - 1750/2200 ml
CVS -S1S2 +
RS - BAE+ ,NVBS
P/A - Soft,non tender
CNS-pupils-NSRL
Power R L
UL 3/5 3/5
LL 3/5 3/5
Reflexes- B T S A K P
R 2+ 2+ 2+ 2+ 2+ flexion
L 2+ 2+ 2+ 2+ 2+ flexion
Investigations:
Cbp: Hb-8.3
Tlc-16300
Plt-1.68lakhs/cumm
Lft:
Tb- 2.9
Db-1.15
Ast-79
Alt-182
All phosphate- 314
Tp-5.8
Alb-3.1
RFT-:
Urea-118
UA-9.9
Cr-4.3
Na+ -137
K+ -5.5
Cl -103
Blood culture:
6Treatment:
IVF - NS, RL u.o+ 30ml/hr
Inj.Thiamine 2amp in 100ml NS/ IV /TID
Tab.Aldactone 50mg/po/bd
Tab.Ecospirin (75/75/20mg) H/S
Tab.Cilnidipine 10mg/po/bd
Salt restricted diet <2g/day
Fluid restriction <2lit/day
Propped up posture
Inj.Lasix 40mg iv/bd
Bp/Spo2-/PR/temp charting 4th hrly
Strict I/O charting hrly
Syp.Lactulose 25ml/po/bd
Syp.Potchlor 15ml in 1 glass of water/po/tid
Syp.Hepamerz 15ml/po/bd
Inj.monocef 1g/iv/bd
Tab.Arkamine 0.1mg od
Tab.pregabalin 75mg po
Inj.lorazepam 4mg IM
Inj.Haloperidol 5mg/im/sos(if pt is irritable)
Inj.Haloperidol 2.5mg/I'm/bd
Nebulization with salbutamol 6th hrly(2respules)
Day 10:
O/E- pt is not oriented to time ,place,person
Temperature - Afebrile
PR- 82bpm
RR - 20cpm
BP- 170/90mmhg
GCS-E4V5M6,15/15
Spo2- 97%@R.A
I/O - 2900/2500 ml
Grbs-114mg/dl
CVS -S1S2 +
RS- BAE+ ,NVBS
P/A - Soft,non tender
CNS-pupils-NSRL
Power R L
UL 3/5 3/5
LL 3/5 3/5
Reflexes- B T S A K P
R 2+ 2+ 2+ 2+ 2+ flexion
L 2+ 2+ 2+ 2+ 2+ flexion
Investigations:
Cbp: Hb-8.3
Tlc-16300
Plt-1.68lakhs/cumm
Lft:
Tb- 2.9
Db-1.15
Ast-79
Alt-182
All phosphate- 314
Tp-5.8
Alb-3.1
RFT-:
Urea-118
UA-9.9
Cr-4.3
Na+ -137
K+ -5.5
Cl -103
Treatment:
IVF - NS, RL u.o+ 30ml/hr
Inj.Thiamine 2amp in 100ml NS/ IV /TID
Tab.Aldactone 50mg/po/bd
Tab.Ecospirin (75/75/20mg) H/S
Tab.Cilnidipine 10mg/po/bd
Salt restricted diet <2g/day
Fluid restriction <2lit/day
Proppped up posture
Inj.Lasix 40mg iv/bd
Bp/Spo2-/PR/temp charting 4th hrly
Strict I/O charting hrly
Syp.Lactulose 25ml/po/bd
Syp.Potchlor 15ml in 1 glass of water/po/tid
Syp.Hepamerz 15ml/po/bd
Inj.monocef 1g/iv/bd
Tab.Arkamine 0.1mg od
Tab.pregabalin 75mg po
Inj.lorazepam 4mg IM
Inj.Haloperidol 5mg/im/sos(if pt is irritable)
Inj.Haloperidol 2.5mg/IM/bd
Day11:
O/E- pt is not oriented to time ,place,person
Temperature - Afebrile
PR- 86bpm
RR - 18cpm
BP- 140/90mmhg
GCS-E4V5M6,15/15
Spo2- 97%@R.A
I/O - 1500/2000 ml
Grbs-103mg/dl
CVS -S1S2 +
RS- BAE+ ,NVBS
P/A - Soft,non tender
CNS-pupils-NSRL
Power R L
UL 3/5 3/5
LL 3/5 3/5
Reflexes- B T S A K P
R 2+ 2+ 2+ 3+ 2+ flexion
L. 2+ 2+ 2+ 3+ 2+ flexion
Investigations:
Cbp: Hb-8.5
Tlc-9600
Plt-1.93
Pt-14
Inr-1
Aptt-28
Cue:
Pus cells-plenty
Epithelial cells- 3-4
Sugars-nil
Albumin- +
RBC- 1-2
Abg:
Ph- 7.46
Pco2-25
Po2-94
Hco3-17.8
RFT:
Urea-145
UA-9.3
Cr-4.6
Na+ -135
K+ -5.4
Cl -104
Treatment:
IVF - NS, RL u.o+ 30ml/hr
Inj.Thiamine 2amp in 100ml NS/ IV /TID
Tab.Aldactone 50mg/po/bd
Tab.Ecospirin (75/75/20mg) H/S
Tab.Cilnidipine 10mg/po/bd
Salt restricted diet <2g/day
Fluid restriction <2lit/day
Proppped up posture
Inj.Lasix 40mg iv/bd
Bp/Spo2-/PR/temp charting 4th hrly
Strict I/O charting hrly
Syp.Lactulose 25ml/po/bd
Syp.Potchlor 15ml in 1 glass of water/po/tid
Syp.Hepamerz 15ml/po/bd
Inj.monocef 1g/iv/bd
Tab.Arkamine 0.1mg od
Tab.pregabalin 75mg po
Inj.lorazepam 4mg IM
Inj.Haloperidol 5mg/im/sos(if pt is irritable)
Inj.Haloperidol 2.5mg/IM/bd
Day12:
O/E- pt is not oriented to time ,place,person
Temperature - Afebrile
PR- 86bpm
RR - 20cpm
BP- 130/80mmhg
GCS-E4V5M6,15/15
Spo2- 98%@R.A
I/O - 1750/2600 ml
CVS -S1S2 +
RS- BAE+ ,NVBS
P/A - Soft,non tender
CNS-pupils-NSRL
Power R L
UL 4+/5 4+/5
LL 4+/5 4+/5
Reflexes- B T S A K P
R 2+ 2+ 2+ 3+ 2+ flexion
L 2+ 2+ 2+ 3+ 2+ flexion
Treatment:
IVF - NS, RL u.o+ 30ml/hr
Inj.Thiamine 2amp in 100ml NS/ IV /TID
Tab.Aldactone 50mg/po/bd
Tab.Ecospirin (75/75/20mg) H/S
Tab.Cilnidipine 10mg/po/bd
Salt restricted diet <2g/day
Fluid restriction <2lit/day
Proppped up posture
Inj.Lasix 40mg iv/bd
Bp/Spo2-/PR/temp charting 4th hrly
Strict I/O charting hrly
Syp.Lactulose 15ml/po/bd
Syp.Hepamerz 15ml/po/bd
Tab.Arkamine 0.1mg od
Tab.pregabalin 75mg po
Inj.lorazepam 4mg IM
Inj.Haloperidol 5mg/im/sos(if pt is irritable)
Inj.Haloperidol 2.5mg/IM/bd
Sleep charts:
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