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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Auscultation of lungs reveals any finding.Patient seems to be developing multisystem involvement.Please give more clear ECG

Acute lvf in a pt of old ihd Require 2decho CAG SOS intervention

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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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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

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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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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Rotation ++ Pleural effusion right

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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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Old antsep mayo inf n right pl eff

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Rotation ++. Pleural effusion right.

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