Concluded Case

elderly pt kn hypothyroidism, DM, HTN cad & kyphoscoliosis.

76yr/M, kn HTN, DM, Hypothyroidism on Rx, Previously operated uneventfully- Ing hernia, TURP, and TKR At present admitted with h/o fever, dyspnea X 2day increasing. Conscious,T- 99.8, HR 96/min, BP 190/80, RR 30/min, SpO2- 84% on air. RBS 160. Rx: observation & continuousmonitoring. RBS, intake/ output, chart. Rx : Oxygen, Nebulisation, dytor, paracetamol, Pantocid, emset, antibiotics - zostum, clindamycine nabicard, cardivas, eltroxin . Labtest : CBC 12/ 12100 / 204000. Clotting & Electrolytes-wnl, sgpt 80 & creatinine 2.6 Trop-I neg, BNP- high. ECG and chest x-ray attached. please do interpretation of the ECG and x-ray and further Rx...

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ECG : sinus rhythm, LAD, lbbb, st- t changes, T wave inversion in l, avf, v5,6 is Inferior wall ischemia . Trop I is negative, high BNP-failure. Echo done - mild MR, trivial TR, EF 40, RVSP 35, Chest x-ray - rotation +, cervico- thoracic scoliosis, bilat mild pleural effusion, rt pleural thickening, mid zone hazyness consolidation, Mild Cardiomegaly. USG abdomen: early renal parenchyma disease, and gall bladder calculi. Continued all above Rx, and in Rx increased diuretic dose, added NTG infusion, tab ramipril, Oxygenation maintained by facemask, nebulisation, bronchodilator & mucolytics . Electrolytes maintained wnl, - iv magnesium given. In acute condition RBS is managed by insulin then oral antidiabetics. Patient is better and doing well. ...

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O/c/o HTN/NIDDM/Hypothyroidism Ecg shows LBBB with old anteroseptal wall MI. Xray suggests - rotation,, - thoracic scoliosis,, - cardiomegaly,, - B/l Mod pleural effusion,, - with mild pericardial effusion.. With COPD..!! Ad- get done 2d echo.. (if possible get done TEE) ABG to get extent of respiratory acidosis.. Usg whole ab pelvis ( hydronephrosis?? CKD??) Routine investigations along with t3t4tsh,, urine routine microscopy culture,, Ad- patient must b treated with proper ICU care with NIV support,. Lasix infusion.. NTG infusion.. I would like to add IV clarithromycin 500mg BD instead of clindamycin.. IV N acetyl cysteine.. Bronchodilators,, mucolytics,, expectorant,, nebulization,, I would prefer to add metalazone 2.5mg Orally BD.. Continue antihypertensive drugs carvedilol 10mg,, ramipril 2.5mg,,nebivolol,,

Nebivolol.. Wrongly typed.. Its nifedipine
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ECG shows deep Q waves in V1 - V4, suggestive of old anteroseptal MI, V5 - V6 shows T wave inversion however Trop I is negative , it may still suggest ischaemia repeat ECG and cardiac enzymes would be advisable Hypertension with raised BNP - suggestive of heart failure Angiotensin receptor and neprilysin inhibitors, are specially meant for this condition and they have been found to have exceptional mortality and morbidity benefits, would be highly recommended in this case X ray shows right pleural effusion, likely to have underline consolidation Cefoperazone sulbactum is good choice of antibiotic, it do not require renal dose adjustment Azithromycin is preferable against clindamycin - to cover Atypical pneumonia pathogen

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Rt upper dorsal thoracic Scoliosis tilt towards rt. Left paracardiac heziness seen. Rt basal costal pleural effusion /thickening likely loculated empyema. ECG NSR left axis deviation. Tall t waves and T wave inversion in lat leads. Needs cardiac enzymes. 2 d echo. Management of hypothyroidism, systolic HTN. Oxygen therapy. Thoracic surgery opinion. Sos intervention. Judicious Diuretics. Antibiotics as per creat clearance.

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Diabetes HTN Hypothyroidism.... Acute onset Fever with Dyspnea.... ECG shows LBBB.....?new onset ?old Xray shows Cardiomegaly with b/l lower zone opacity and CP angle obliteration (Rt) ... Acute LVF with ?ACS Do Enzymes and give NIV

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ECG : sinus rhythm, LAD, lbbb, st- t changes, T wave inversion in l, avf, v5,6 is Inferior wall ischemia . Trop I is negative, high BNP-failure. Echo done - mild MR, trivial TR, EF 40, RVSP 35, Chest x-ray - rotation +, cervico- thoracic scoliosis, bilat mild pleural effusion, rt pleural thickening, mid zone hazyness consolidation, Mild Cardiomegaly. USG abdomen: early renal parenchyma disease, and gall bladder calculi. Continued all above Rx, and in Rx increased diuretic dose, added NTG infusion, tab ramipril, Oxygenation maintained by facemask, nebulisation, bronchodilator & mucolytics . Electrolytes maintained wnl, - iv magnesium given. In acute condition RBS is managed by insulin then oral antidiabetics. Patient is better and doing well. ...

Ecg suggest acute st-t changes suggestive of ACS and xray chest shows rt pleural effusion with shifting of trachea to rt due to rotation and cardiomegaly Important to note is marked increase in tlc from 12100 to 204000 with renal failure as sr creatinine are 2.6 hence i take it septicemia secondary to pleural effusion with septicaemic acs prognosis seems to be poor should be treated in icu pt has highbsl to be managed with insulin as he is kc o of ht dm hypothyroidism and has turp and tkr ie multiple systems involved

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QS complexes from V1toV4 T inversion v5 V6,I,avl,Lt axis Cardiomegaly, rt pleural effusion and raised Pro BNP suggest ischaemic cardiomyopathy with CHF. Go for ECHO. Decongestive therapy Stop nabicard and cardivas start once patient stablizes and CHF improves. Nabicard and cardivas both are B blockers. Give only one.

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As given history Patient in LVF O2 support Diuretics NTG infusion Serum protein albumin 2decho Cardiac opinion Urine routine Usg abdo pelvis Uric acid serum calcium magnesium Sos nephro opinion Control sugar

Serum creatinine raised stemi q wave lead 3 t wave inverted@1 v5 v6 xray rt lower pneumonia cardiomegaly HRC t for dd

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Rotation ++. Pleural effusion right.

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