43 y male On ATT since 9 months Brought to er with c/o breathing difficulty since theee days and fever . BP -120/90 on norad 15 ml per hour Temp - 98.3 f Urine output decreased Correlate ecg and abg with CXR and advice further treatment

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X-ray shows fibrocavity Rt>Ltwith B/L consolidation Lt>Rt with diffuse nodular infiltration S/O MDR TB with Secondary infection (probably was on Cat 2). ECG :Sinus bradycardia with hypokalemia with low voltage criteria. ABG showed acidosis (pH low),hypernatraemia, hypercalcaemia, hypokalemia. Investigation: Sputum AFB/CBNAAT,LFT,TSH,RFT,CBC,ESR,BSL. Treatment:IV fluids with 1 amp KCL & 1 amp Sodibicarb,Moist O2 inhalation,Inj Pipercilin Tazobactum 4.5 gm IV BD, Nebulization with Budecort & Duolin respules.PCM sos,Inj Vitnurone BD. ATT to start on MDR management. Monitor vitals, Rept ECG to assess any u wave or any other electrolyte abnormality.After. Pt is stable may start only oral medication & continue inhaler.

X-ray consolidation b/l, huge consolidation in the left, cavitary lesions b/l. ABG - uncompensated metabolic Acidosis, hypernatremia, hypokalemia, hypocalcemia, high AGap. ECG shows sinus rhythm, regular, 60 bpm, Axis LAD, LAFB, 1st degree AV, low voltage QRS, U wave indicates hypokalemia, ST - T nonspecific. Reactivation of the old pulmonary Koch's with uncompensated metabolic Acidosis, and dyselectrolytemia. Do Sputum for AFB, if negative then do CBNAAT. CBC, RBS, LFT, RFT, Urine for RE and ME.

Thank you Sir
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Pt is in metabolic acidosis seems to be dehydrated as there is oligourea ecg show bradycardia 60 to 65 bpm sinus rythm. Chest xray shows massive lesion on lt mid and lower zone ie cavity full of nodular infiltrates as well as there are infiltrates on rt side also and fibrovascular cavity rt lower zone seems to old lesion this looks to be flareup c/o MDR pultb.mx Genxpert test and start second line with management of metabolic acidosis.

Thanx dr VedPrakashSharma
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They have metabolic acidosis with high anion gap + respiratory acidosis and secundary alkalosis respiratory. AV gradient elevated may be hipoxemia more CO2 retention. Dehydrated condition hypernatremy and water deficit 5L approx. Hypokalemia related to dehydration. Rx thorax with left pulmonary condensation probably related to pneumonia with extensive pulmonary fibroses. Where is the kidney profile? Creatinine, BUN, glucose...

Rules of Emergency- Never Judge potassium levels from ABGA, they always tend to be lower. A metabolic acidosis with poor respiratory compensation se basically a metabolic plus respiratory acidosis. Avoid bicarbonate in patients with respiratory acidosis, as it will worsen it.

Bil mid and lower zone heziness more on left.rt sided cavitary lesion seen. ABG:met acidosis. ECG sugg low voltage complex in limb leads,LAD Prov diagnosis: Sepsis ARDS, cardiogenic shock.

Hypokalemia -ECG reveals U waves. X -Ray reveals Bilateral infiltration. Consolidation L mid zone. Cavity R mid zone . Superadded secondary infection leading to septicaemia.

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Cxr lf>RT consolidation H1n1 to rule out Et gram stain c/s and broad spectrum abx with tamiflu to start Abg: HAGMA + respiratory acidosis + met alkalosis Ecg: low voltage LAD and U wave seen As inotropes on high support If norad requirement is increasing then add vasopressin and calcium chloride through cvp Controlled acidosis If affordable then life saving cytosorb dialysis will give promising result

ATT with superimposed with secondary infection. Considering ABG patient is in respiratory acidosis as because of severe consolidation. Sinus bradycardia with T negative in V1.

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