60F with left diaphragmatic palsy with type 2 RF and Respiratory Acidosis with Diabetic ulcer over Left lower limb with AKI on CKD with Anemia

DOA: 21/1/2023
DischargeDate 
DATE:2/2/23 
WARD:AMC
 UNIT:6

Diagnosis
LEFT DIAPHRAGMATIC PALSY WITH EVENTRATION
WITH TYPE 2 RESPIRATORY FAILURE AND RESPIRATORY ACIDOSIS
+ ANASARCA
+ DIABETIC ULCER OVER LEFT LOWER LIMB
+ AKI ON CKD WITH ANEMIA
+ DEXTROPOSITION OF HEART
+ HYPOTHYROIDSM AND DM (SINCE 20 YEARS)

Case History and Clinical Findings
PATIENTCAMEWITHC/OPEDALEDEMASINCE1MONTHAND BREATHLESSNESS SINCE 3 DAYS

HOPI: PATIENT WAS APPRENTLY ASSYMPTOMATIC 20 YEARS BACK , THEN WAS DIAGNOSED WITH DM,HYPOTHYROIDISM AND IS ON REGULAR MEDICATION SINCE THEN.C/O SOB SINCE 6 MONTHS ON &OFF , INITIALLY GRADE 2 >GRADE4(PAST2
MONTHS)FORWHICHCARDIOLOGISTADVISEDT.ASPIRIN,TCLOPIDOGREL,TATORVAS. C/OB/LPITTINGPEDALEDEMASINCE1MONTHGRADUALLYPROGRESSEDTOANASARCA AND WAS TREATED CONSERVATIVELY FOR THE SAME .ON JAN 15TH , PATIENT WHILE BEING TAKEN TO GOVT HOSPITAL UPON BEING REFERRED FROM LOCAL HOSPITAL I/V/O SYNCOPE , SHE HAD INVOLUNTARY MOVEMENTS , MICTURITION+ AND LOC (REGAINED CONSCIOUSNESS AFTER 1 HR) FOR WHICH SHE WAS ADMITTED FOR 3 DAYS.SINCE YESTERDAY(20/1/23@10AM)PATIENTHADCARDIACARRESTFOLLOWINGSEVERESOB, POSTWHICHCPRWASDONEATANEARBYHOSPITALANDPATIENTWASREVIVEDAFTER 10MIN AND WAS REFERRED TO OUR HOSPITAL.

PAST HISTORY:
K/C/ODM,HYPOTHYROIDISM:20YEARSANDONREGULARMEDICATION NO H/O HTN/EPILEPSY/TB/CVD.
H/OHYSTERECTOMY10YEARSBACKFORAUB
 PERSONAL HISTORY :
APPETITE-NORMAL DIET - MIXED
BOWELANDBLADDER-REGULAR SLEEP - ADEQUATE

GENERAL EXAMINATION :
PT IS C/C/C
NOPALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY,PEDALEDEMA VITALS ON ADMISSION:
TEMP-98.2F PR-116 BPM
BP-120/60MMHG RR-25 CPM
SPO2- 96% ON 3LT OF O2 GRBS - 322 MG/DL 
SYSTEMICEXAMINATION:
1) PER ABDOMEN:
INSPECTION:UMBILICUSISCENTRALANDINVERTED,ALLQUADRANTSMOVINGEQUALLY WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.
PALPATION:SOFT,NONTENDER.NOORGANOMEGALY. ASCULTATION: BOWEL SOUNDS - HEARD 
2)RESPIRATORY SYSTEM:
INSPECTION:SHAPEOFTHECHESTISELLIPTICAL,B/LSYMMETRICAL.BOTHSIDESMOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.
 PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL
IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL .VOCAL FREMITUS IS NORMAL
PERCUSSION: RESONANT B/L
ASCULTATION: BAE + , NVBS HEARD, DECREASED BREATH SOUNDS IN B/L IAA
CVS:
INSPECTION:B/LSYMMETRICAL,BOTHSIDESMOVINGEQUALLYWITHRESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.
PALPATION:APEXBEATFELTINLEFT5THICS.NOTHRILLSANDPARASTERNALHEAVES. ASCULTATION: S1S2 +,NO MURMURS
CNS:
PATIENT WAS C/C/C.
HIGHER MENTAL FUNCTIONS- INTACT
B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT
NOSIGNSOFMENINGEALIRRITATION,CRANIALNERVES-INTACT,SENSORYSYSTEM- NORMAL,
MOTOR SYSTEM: TONE- NORMAL, POWER- 3/5 IN ALL LIMBS
REFLEXES : BICEPS - 1+ , TRICEPS-1+ , SUPINATOR - ,KNEE - 1+ , ANKLE - 1+

REFERRALS TAKEN :
SURGERY REFERRAL I/V/O LEFT LEG ULCER AND REGULAR DRESSINGS DONE

Investigation
HEMOGRAM:
>22/01/23-------------------24/1/23--------------26/1/23------28/1/23------30/1/23 31/1/23
HB:9.1 MG/DL 7.2 7.6 8.5 TLC:16,000CELLS/CUMM PLAT: 2.8 LAKH/CUMM
HRCTTHORAX:ELEVATEDLEFTDOMEOFDIAPHRAGMASCOMPAREDTORIGHTSIDE WITH BASAL LUNG COLLAPSE SUGGESTIVE OF LEFT DIAPHRAGMATIC EVENTRATION / PALSY
USG ABDOMEN: GALL BLADDER SLUDGE +
BLOOD C/S: NO GROWTH
URINE C/S:NO GROWTH
C/S OF PUS FROM ULCER ON 30/1/23 : PLENTY OF PUS CELLS , FEW GRAM POSITIVE COCCIINCLUSTERS,OCCASIONALGRAMNEGATIVEBACILLISEEN:ESCHERICIACOLI ISOLATED [ SESNITIVITY TO GENTAMICIN,AMIKACIN &MEROPENEM ]

Treatment Given(Enter only Generic Name)
O2 SUPPLEMENTATION TO MAINTAIN SATS >94%
INJ LASIX 60MG IV BD ( 8AM-X-4PM)
INJ HAI S/C ACC TO GRBS TID (8AM-12PM-8PM)
T ECOSPRIN AV 75/20 PO/ H/S
T THYRONORM 100MCG PO OD
T CARVEDILOL 3.125MG PO TID
OINT THROMBOPHOBE L/A TID
GRBS CHARTING 6TH HRLY ( 8AM-2PM-8PM-2AM)
STRICTINPUT/OUTPUTCHARTING MONITOR VITALS / INFORM SOS

BRIEF COURSE:
PATIENTPRESENTEDWITHABOVEMENTIONEDCOMPLAINTSANDHADSATURATIONSOF 68% ON RA,98% ON 2LT OF O2.CHEST XRAY SHOWED ELEVATED LEFT HEMI DIAPHRAGM WITH OPACIFICATION OF LEFT LOWER LUNG AND 2D ECHO REVELED THAT HEART IS ON RIGHT SIDE AND HRCT WAS DONE I/V/O SUSPICION OF LEFT DIAPHRAGMATIC PALSY
,WHICH REVEALED ELEVATED LEFT DOME OF DIAPHRAGM AS COMPARED TO RIGHT SIDE WITH BASAL LUNG COLLAPSE SUGGESTIVE OF LEFT DIAPHRAGMATIC EVENTRATION / PALSY WITH MEDIASTINAL SHIFT TO RIGHT SIDE (ON CLINCAL SUSPICION OF DEXTRO POSITION OF HEART).PATIENT WAS INITIALLY TREATED WITH INTERMITTENT CPAP FOR TYPE 2 RESPIRATORY FAILURE AND LATER ON PATIENT WAS MAINTAINING ON 2LT OF O2 WITH SATURATION OF 98%.DOPPLER OF LEFT LOWER LIMB WAS DONE , I/V/O ULCER ON LEFT LOWER LIMB SUSPECTING ? VENOUS ULCER / ? DIABETIC ULCER WHICH REVEALED TO BE NORMAL . SO ULCER HAS BEEN ATRIBUTED TO BE DIABETIC ULCER AND SURGERY REFRREAL WAS TAKEN AND PATIENT WAS GIVEN INJ.PIPTAZ 2.25MG IV TID AND INJ CLINDAMYCIN600MGIVTID&DRESSINGSWEREDONEEVERYALTERNATEDAYINSPITEOF WHICHULCERWASNONHEALINGANDECOLIHASBEENISOLATEDFROMTHESWABSENT [ ON 30/1/23 SENSITIVITY REPORT ATTACHED]. FOR LEFT DIAPHRAGMATIC PLICATION SURGERY , CTVS OPINION TAKEN FROM(DR.RAJESH , KHL) WHERE IN SHE WAS ADVISED FOR SURGERY THUS PATIENT IS BEING REFERRED TO KHL FOR BETTER OUTCOME.

Advice at Discharge
FOR LEFT DIAPHRAGMATIC PLICATION SURGERY , CTVS OPINION TAKENFROM(DR.RAJESH KHL) , WHERE IN SHE WAS ADVISED FOR SURGERY , THUS PATIENT IS BEINGREFERREDTOKHLFORBETTEROUTCOME(WITHHERSATSBEING96%ON1LTOF O2 ).

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