C H R I S T I A N M E D I C A L C O L L E G E AND HOSPITAL , L U D H I A N A
DISCHARGE SUMMARY
DEPARTMENT OF MEDICINE
UNIT - 3
(REGISTERED SOCIETY UNDER ACT NO XXI OF 1860 AS A CHARITABLE MINORITY INSTITUTION)
LUDHIANA 141 008, PUNJAB (INDIA)
General OPD; 0161-211-5226, Private OPD -0161-211-5258, 5252, 5264, Office -0161-211-5731
CONSULTANT INCHARGE CONSULTANTS PG RESIDENTS
Dr. Navjot Singh, MD, Dr. Divya Varghese, MD, Assistant Professor Dr. Eric Williams
Professor Dr. Eldhose
Dr. Kripa Anna
Dr. Suraj Kumar
PATIENT NAME UNIT NO AGE GENDER
Gurpreet 8068248 42years Female
DOA DOD WARD
2/9/22 15/9/22 5
FINAL DIAGNOSIS
Scleroderma
Shock-?septic
Severe pumonary hypertension
CLD under evaluation(? Autoimmune hepatitis)
Venous thrombosis(to r/o APLA)
Hypothyroidism
Anemia-microcytic, hypochromic( Iron Deficiency Anemia)
S/P splenectomy
PRESENTING COMPLAINTS
Generalised weakness since 3 days
Nausea since 1 day and vomiting since 1 day
ON EXAMINATION:
BP PULSE RESPI RATORY RATE TEMPERATUR Saturation
RATE E
80/?mmhg 93/min 24/min Afebrile 100% on 4L
face mask
PALLOR ICTERUS CYANOSIS CLUBBING LNE JVP EDEM
A
Present Absent Absent Absent Absent Not Absent
elevated
RESPIRATORY SYSTEM : bilateral normal vesicular breath sounds
CVS:s1 s2 heard, loud s2, palpable p2
PER ABDOMEN:soft nontender
CNS: no focal neurological deficits
Biceps Supinator Triceps Knee Ankle Plantar
Right + + + + + Flexor
Left + + + + + Flexor
INVESTIGATIONS
HAEMATOLOGICAL:
HB DLC
Dat Retic PC ES WBC Plat. MC RD
(gm N L E MM PT PTTK INR
e %)
s V R (cumm) (lakh) V W
% % % %
35. 17.1/12.0 25.6/28 1.4
2/9 9.5 20 14200 88 11 0 1 1.01 71.6 25.4
0 4
5/9 8.7 30. 10500 70 23 0 3 13000
1
6/9 9.4 32. 10600 63 31 4 2 15000
2
7/9 10.6 35.8 9100 70 24 3 3 27000
8/9 9.9 33.7 13600 75 20 5 0 23000
9/9 10.5 35 13700 65 27 6 2 43000
12/9 10.3 35.9 12800 63 30 4 3 64000
15/9 9.9 33.8 9000 53 28 5 11 1.66L 44.4/12 29.5/28 3.89
Rbc-anisocytosis, microcytes, few macrocytes, few macro ovalocytes, elliptical tear drop cells, target cells
Wbc-leucocytosis with neutrophillia, nornal morphology
Platelets-adequate with few large forms
BIOCHEMICAL PARAMETERS:
Hba1 Cortisol Procal
Dated RBS BU CR NA K Crp Ca Mg
c
2/9 122 45 0.64 143 3.9 12 8.4 1.57 5.4 22.76 2.17
5/9 52 0.48 138 3.6
6/9 36 0.45 137 3.2
7/9 140 3.2
8/9 0.44 136 3.3 10.3 0.129
9/9 0.3 138 3.6
10/9 130 4.1
12/9 134 4
15/9 22.0 0.24 136 4.2
T. B D. B T. P Alb ALP GGT SGOT SGPT HIV HCV HBsAg
2/9 1.9 1 .18 6.1 2.9 275 171.9 65.7 63.7 Neg Neg Neg
15/9 2.8 77 87
ABG:-
Dated PH PCO2 Po2 HCO3 Sat Na+ K+ Lac
2/9 7.416 22.1 96.3 13.9 96.7 3.1
3/9 7.46 15.6 72.1 11.1 96.4
ECG Normal
CHEST X-RAY Normal
ECHO DilatedRA, RV, Severe TR RVSP 70mmhhg, severe pulmonary hypertension,
trivial MR, AR, grade 11 diastolic dysfunction of LV, LVEF 55%
USG ABDOMEN Coarse echotexture of liver with absent flow in the distal part of portal vein?
Portal vein thrombosis
URINE CULTURE Rbc 5, wbc 20, no growth final
BLOOD CULTURE No growth final
URINE ROUTINE Neutral, protein neg, sugar neg, PC 1-2, EC 4-5, RBCnil
Tft
Tsh 1.45
T3 2.17
T4 18.09
P falciparum Neg
P vivax Neg
Ns1ag Neg
Anemia panel
Ferritin 28.4
UIBC 234
TIBC 261
S.Fe 27
Folic acid 9
Vit B12 755.7
Ana profile
SS B/La 2+
Scl 70 1+
Ana hep 2 Positive , granular pattern
Cect abdomen Mottled appearance of liver with portal vein thrombosis, multiple
periportal and para esophageal collaterals.
Enhancing soft tissue density lesions in left hyppochondrium and
adjacent to left renal hilum
Pericardial effusion with cardiomegaly
PROCEDURES :
MEDICATIONS GIVEN:
Inj meropenem, inj targocid, tab itraconazole, inj pantop, inj lasix, tab thyronorm, tab divery,
tab folic acid, tab livogen, syp potklor, tab hcq, tab avas 10, tab acitrom
DISCUSSION : Mrs Gurpreet 40 year old hypothyroid patient, presented to the emergency
room with chief complaints of generalised weakness since 3 days, nausea and vomiting since
1 day.At presentation, she was conscious oriented,had facial puffiness and oral candidiasis.
Her Bp was 80/? and saturation 100% on 4L face mask. She was shifted to medical hdu on
inotropic supports with a working diagnosis of shock under evaluation. Central venous
pressure was 24 , hence her intake was restricted . She was initiated on inj Meropenem, Inj
Targocid, tab itraconazole and other supportive measures . She was continued on inotropic
supports till her Blood pressure stabilised. Relevant blood and urine investigations were done
which revealed thrombocytopenia. However, she did not have bleeding manifestations or
require transfusion. In the background of thrombocytopenia, febrile serology including
dengue IgM were sent which was negative. Echo was done in view of her unexplained
hypotension and it revealed severe pulmonary hypertension without any functional cardiac
defect. She was started on diuretics as tolerated and doses were titrated appropriately. Hrct
chest was done and pulmonary causes of pulmonary hypertension was ruled out. As part of
further evalutaion on the above regard, autoimmune workup was done which revealed ANA
SSB , SCL 70 and hep2 positivity. Updated diagnosis of severe pulmonary hypertension
secondary to scleroderma/ mixed connective tissue disorder was made. Cect abdomen and
usg abdomen was done which showed portal vein thrombosis and coarse echo texture of
liver. Hence, Apla and autoimmune hepatitis workup was also done. She was started on tab
hydroxychloroquine. Oral anticoagulants were initiated in view of thrombosis, PT INR was
monitored and need titration of doses.Patient is currently stable and is being dicharged on
request with the following recommendations.
RECOMMENDATIONS
S.No Type Name Dosage Times Days
Tab Acitrom 1mg Orally, at 1
night
Tab Pantop 40mg Orally 5
once
daily,
empty
stomach
in the
morning
Tab Lasix 10mg Orally, 5
twice daily
Tab Thyronorm 125mg Orally, 5
once daily
empty
stomach
in the
morning
Tab Divery 20mg Orally, 5
thrice
daily
Tab Folic acid 5mg Orally 5
once daily
Tab Livogen One tab Orally, 5
once daily
Tab Hydroxycholoroquin 200mg Orally, 5
twice daily
Tab Avas 10mg Orally, 5
once at
night
NUTRITIONAL CARE-high protein diet
URGENT CARE / OTHER RECOMMENDATIONS
FOLLOW UP in opd on 16/9/22 with platelets, pt INR report.
To decide on acitrom dose
SIGNATURE AND STAMP
Dr. Kripa Anna/ Dr. Suraj Kumar Dr. Eldhose / Dr. Eric Dr. Divya Varghese
P.G Resident P.G Resident Assistant Professor
Department of Medicine Department of Medicine Department of Medicine
Received By: Relation:
Date: Time:
