Date : 03/01/24

MEDICAL SUMMARY

LINGAMPELLI KASHIRAM 69/MALE

CONSULTANT Dr. JAYESH N. DESAI

69/ male patient admitted in wards dept of Maratha Mandir Babasaheb Gawde hospital
on 31/12/23 at 03:35 am under care of Dr. Jayesh desai with C/O FEVER WITH CHILLS SINCE SINCE 2
DAYS GENERALIZED WEAkNESS. In K/C/O HTN with IHD Post PTCA status, on admission pt had 99F
temp with BP 90/60 hence fluid challenge given patient resoponded well to it, on investigation pt
had TLC 20800, HB 13.5, plt 143000, Sr. Creat 2.21, urince routine 3-4 pus cells, Rmt, psmp, dengue
negative,

Pt started in broadspectrum antibiotics and other rx, foleys inserted for urine monitoring and
conservative medical management started for AKI.

On 1/1/24, patient remained febril with TLC 19200, HB 13.1, plt 103000. u/o of 31/12/23, 1500 ml
with intake of 2400 ml, hence antibiotics escalated to piptaz in renal dose.

In evening of 1/1/24 pt developed atrial fibrillation with FVR with hypotension hence pt shifted to icu
and cordarone started, inotropic support started and antibiotics escalated.

On 2/1/24 TLC 35000, HB 12.7, plt 102000. u/o of 01/01/24, 250 ml with intake of 1650 ml.
Antibiotics further escalated and inotorpic support escalated and inj lasix infusion started i/v/o
hypotension and poor urine output. 2D ECHO LVEF 40-45 % WITH RWMA+

On 3/1/24 TLC 41000 , HB 13.6 , plt 125000. u/o of 02/1/24, 110ml with intake of 910ml

At present vitals

BP 90/60 ON TRIPLE INOTROPIC SUPPORT, P 142/min atrial fibrillation, spo2 90% on bipap with 4
lt/min o2 support. Rr 22/min. Rs b/l crepts +, CNS conscious and alert.

At present pt is on rx.

INJ VIVEM PLUS 500 TDS INJ NORAD 16MG/50ML @ 10ML/HR

INJ METRO 100 ML TDS INJ DOPAMINE 400MG/50ML@ 4ML /HR
INJ TARGOCID 200 ML OD INJ VASOPRESSIN 40MG/50ML @ 3 ML/HR
INJ FLUCON 100 ML OD TAB IVABRAD 5MG TDS
INJ PAN 40MG BD NEB- DUOLIN + BUDECORT BD
INJ EMSET 4 MG TDS TAB ZYTANIX 5 BD
INJ EFFCORLIN 50MG TDS TAB TETRAFOL PLUS BD
INJ LASIX @ 4ML/HR CAP FLUVIR 75 OD
CARDARONE 900/50 @ 2ML/HR