advice for treatment
History of present illness:
admitted in hospi.. on June 2 as a case of acute pulmonary arrest after vomitting & sudden SOB and AMS with renal tumor SIP ..
Tumor on rt idney for last 4 years believed to be malignant but dormant...
Weak in health but stable and discharging
Past surgical history:
On ventillator, IVF, dopamine drops and antibiotics....
Reports suggest aspiration pneumonitis, septisemia and ARF ...
Treated along conservative line of treatment...
He has been a senior federal govt executive, retired in 1976.
Has well settled compact family. Wife expired 5 years back due to pulmonary failure..
Longevity in family , his parents lived healthy life up to 90's without heart / kidney problems.. but had respiratory problems...
Gen condition : presently low
otherwise normal for
Regular with YOGic exercises.
Height : 5' 7"
Weight : 64 Kg.
B.P. 80/ 60 with Ionotropic support
P.R. 96 Resp rate 22 SPO2 92
Chest : Bilateral clear with occasional crept.
100/60 but varying over the day upto 120/70
22 per minute
Head, ears, eyes, nose & throat:
Head, ears, eyes responding when spoken to.
Sputum has to be extracted but is improving interms of rate output.
Oxygen supply through tube in mouth and there is soreness.
no congestion, abnormality
drowsy, semi-consious, pupil bilateral, NSNR, planter bilateral flexus
right kidney shows a mass of 64mm on lower pole
ABG pH 7.4
Hb 13.2 TLC 14800 DLC C 80
B.P not maintained.
Consciousness level not improving
Plan of treatment:
gradually weaning from ventilator and external O2 supply to be decreased.
Endotrachial tube to removed
B.P to be maintained without support
Overall general condition to improve
Results of treatment:
consciousness better but still drowsy.
B.P maintained with support only.
genral condition fair
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