Medicine ICU case

  This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.


Tuesday,November 30


A 56 year old male came with altered sensorium,fever 


B.Sushma ,9th semester

Roll no.154

November 30th,2021


I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.


CASE PRESENTATION:

50 yrs male resident of miryalaguda

 CHIEF COMPLAINTS

Fever and altered sensorium

HISTORY OF PRESENT ILLNESS

Fever: high grade associated with chills and rigor not associated with loose stools head ache,cold,cough,seizerus and loss of consciousness 

Pt was apparently asymptomatic 6 yrs back then he had thrown prick to right leg  because of nonhealing ulcer on routine investigation he was diagnosed with dm and htn and on irregular medication 

2 yrs back complaints of pedal edema  insidious onset gradullay progressive extent up to b/l knee not associated with decreased urine output facial puffiness frothing urine

Pt was admitted in hyd with c/o pedal edema and sob and diagogoned with renal failure ,5 dialysis sessions were done

Since then pt was on medical management  pt had no complaints for 8 months

Then developed vomiting and loose stools 15 days back visited our hospital and pt was innitiated on dialysis in view of metabolic acidosis

Pt was twice weekly on dialysis

PERSONAL HISTORY 

Married 

Occupation : daily wage worker

Diet : mixed

Appetite : decreased

Bowel and bladder : Regular 

No addictions .

No known allergies .


FAMILY HISTORY 

K/C/O HTN , DM on medcation which are not known

GENERAL EXAMINATION 

Patient is altered sensorium

No Pallor, icterus ,cyanosis, clubbing , lymphadenopathy , edema.

VITALS 

TEMP : 98.6

BP : 120/ 80 mmhg

PR : 92/ min

RR : 20/ min 

Spo2 : 98% on RA



SYSTEMIC EXAMINATION 

CVS : S1, S2 + 

RS : BAE + , NVBS 

P/A : SOFT , NON TENDER 

CNS : 

PATIENT IS altered sensorium not orinted with time place person

SPEECH : SLURRED 

SENSORY SYSTEM : INTACT 


MOTOR SYSTEM :  

                               R                         L 

TONE      UL    Increased.            -

                  LL      Hypotonic          -

       

POWER     UL       1/5                  3/5 

                   LL       1/5                  3/5

  

REFLEXES

 

         B      T      S      K        A         P


R      1+     1+     -       -          -         Flexor


L       1+    1+   1+     -          -         Flexor


Gcs: E4V1M4

 Meningeal signs: neck stiffness +

REPORTS:

22/11/2021



24/11/2021

Blood urea:266mg/dl

Serum creatinine:6.3mg/dl

Uric acid:8.1mg%

Na-139mEq/L

K-3.6mEq/L

Cl-92mEq/L

Phosphorus:3.8mg/dl

CBP


LFT


ECG


25/11/2021

Hemogram



CBP


RFT


2D ECHO


CSF Analysis


26/11/2021

Chest x-ray


Ultra sound



ECG




Hemogram




RFT


Bacterial culture


ABG

Prothrombin time:21sec
APTT test:40sec


27/11/2021

X-Ray 



ECG


Bacterial Culture



Referals:

24/11/2021  Ophthalmology


25/11/2021  DVL



CLINICAL PICTURES:



Patients left hand

Patients Right hand





TREATMENT GIVEN :

HEMODIALYSIS on 25/10/21,28/10/21,2/11/21,6/11/21,  21/11/21(WITH PRBC),  24/11/21( with PRBC),25/11/21 ( WITH PRBC)


Inj DEXAMETHASONE 8 MG IV/BD

RT FEEDS -100ML MILK@4TH HOURLY 

              - 100 ML WATER @ 4TH HOURLY

INJ PAN 40 MG IV OD 

TAB NODOSIS 500 MG /RT/BD 

TAB SHELCAL CT RT/OD

TAB OROFER XT RT/BD 

INJ ERYTHROPOIETIN 4000 IU /SC/WEEKLY ONCE 

INJ FALCIGO 120 MG IV (0,12,24,48 HRS )

INJ MEROPENAM 500 mg IV/BD

FLUID RESTRICTION < 1 L / DAY 

SALT RESTRICTION <2 gm /day 

INJ HAI S/C ( INFORM GRBS TO PG)



Soap notes :26/11/21


S- fever spikes+, fluctuating between drowsiness and aggitated state.

O- pt is c/c/c

GCS:E3,V1,M3

palpable petechiae on the palms and soles ,dermatology opinion taken- purpura fulminans.

afebrile

pr-86/min

bp-120/80mmhg

spo2-98%with 6lit o2

r.s-bae+end insp crepts in rt isa,iaa

r.r-20/min

cvs:s1,s2+

p/a:soft,nt

cns:pupils: normal size sluggish reaction to light

reflexes: b t s k a :absent

plantars: b/l upgoing

brudzink's :+

kernig's:+

speech:aphasia


grbs-8am-222mg/dl-8hai

i/o:800/300ml since 8hrs

egfr:12.8ml/min/1.73m2

one session of HD yesterday

A-  aphasia with altered sensorium secondary to meningoencephalitis ? bacterial 

?DIC sec to sepsis 

chronic kidney disease oh HD

dm2

anaemia, thrombocytopenia

P- rt feeds 

inj dexamethasone 8mg/iv/bd

inj meropenem 500mg/iv/bd

tab pcm 650mg/rt/sos


Soap notes 27/11/21


S- no fever spike since 8am yesterday

did not pass stool since 4 days

loss of speech

aggitated in between

awake for most time compared to yesterday.

O- pt is conscious,not coherent,not 

GCS:E4 V1,M4

palpable petechiae on the palms and soles ,dermatology opinion taken- purpura fulminans.

afebrile

pr-89/min

bp-110/70mmhg

spo2-94%with 2lit o2

r.s-bae+end insp crepts in rt isa,iaa

r.r-18/min

cvs:s1,s2+

p/a:soft,nt bs+

cns:pupils: normal size sluggish reaction to light

reflexes: b t s k a :absent

plantars: b/l upgoing

brudzink's :+

kernig's:+

speech:aphasia


grbs-8am-195/dl-8hai

i/o:1000/650 since 8hrs

egfr:12.8ml/min/1.73m2

2FFP's transfused yesterday

blood and csf culture negative for any growth

A-  aphasia with altered sensorium secondary to meningoencephalitis ? pyogenic ?tubercular

?DIC sec to sepsis 

chronic kidney disease oh HD

dm2

anaemia, thrombocytopenia

P- rt feeds 

inj dexamethasone 8mg/iv/bd

inj meropenem 500mg/iv/bd

tab pcm 650mg/rt/sos

tab att- H-300mg,R-600mg,Z-1500 mg,E-900/RT/OD

28/11/21 


S- 

loss of speech+

Awake and alert for most of the time

Fever spikes +

O- pt is conscious, coherent, 

GCS:E4 V1,M6

palpable petechiae on the palms and soles ,dermatology opinion taken- purpura fulminans.

afebrile

pr-85/min

bp-110/70mmhg

spo2-98%with 3lit o2

r.s-bae+

r.r-15/min

cvs:s1,s2+

p/a:soft,nt bs+

cns:pupils: normal size sluggish reaction to light

reflexes: b t s k a :absent

plantars: b/l upgoing

brudzink's :+

kernig's:+

speech:aphasia


grbs-8am-204/dl-6hai

i/o:1500/500 

egfr:12.8ml/min/1.73m2

2FFP's transfused yesterday

blood and csf culture negative for any growth

A-  aphasia with altered sensorium secondary to meningoencephalitis ? pyogenic ?tubercular

?DIC sec to sepsis 

chronic kidney disease oh HD

dm2

anaemia, thrombocytopenia

P- rt feeds 

inj dexamethasone 8mg/iv/bd

inj meropenem 500mg/iv/bd

tab pcm 650mg/rt/sos

tab att- H-300mg,R-600mg,Z-1500 mg,E-900/RT/OD


29/11/21 


S- one fever spike at 6pm 100F

passed stools today

able to talk, asking for rice to eat

O- pt is conscious,coherent,oriented to person,place


palpable petechiae on the palms and soles ,dermatology opinion taken- purpura fulminans.

afebrile

pr-103/min

bp-130/70mmhg

spo2-92%on ra

r.s-bae+end insp crepts in rt isa

r.r-18/min

cvs:s1,s2+

p/a:soft,nt bs+

cns:pupils: normal size sluggish reaction to light

reflexes: b t s k a :absent

plantars: b/l upgoing

brudzink's :+

kernig's:+

speech:naming+ 

non fluent+no repetition


grbs-187mg/dl-4units hai

i/o:1500/500 ml

egfr:12.8ml/min/1.73m2


blood and csf culture negative for any growth

A-  aphasia with altered sensorium resolved) secondary to meningoencephalitis ? pyogenic ?tubercular

DIC sec to sepsis -resolving

chronic kidney disease oh HD

dm2

anaemia, thrombocytopenia(improving 25k-40k)

P- rt feeds 

inj dexamethasone 8mg/iv/bd

inj meropenem 500mg/iv/bd

tab pcm 650mg/rt/sos

tab att- H-300mg,R-600mg,Z-1500 mg,E-900/RT/OD


csf-cbnaat pending.


30/11/21 


Soap notes 

S- pt' is talking one or two words, awake for lesser period than before.


one episode of svt (af)-post dialysis with  hr -180-190/min,resolved with injection metoprolol 5mg.

O- pt is conscious,coherent,oriented to person,place

afebrile

palpable petechiae on the palms and soles ,dermatology opinion taken- purpura fulminans.

afebrile

pr-101/min

bp-120/80  mmhg

spo2-92%on ra

r.s-bae+end insp crepts in rt isa

r.r-22/ min

cvs:s1,s2+

p/a:soft,nt bs+

cns:pupils: normal size sluggish reaction to light

reflexes: b t s k a :absent

plantars: b/l upgoing

brudzink's :+

kernig's:+

speech:naming+ 

non fluent+no repetition


grbs-167 mg/dl

i/o:1150/1300

egfr:12.8ml/min/1.73m2


blood and csf culture negative for any growth

A-  aphasia with altered sensorium resolved) secondary to meningoencephalitis ? pyogenic ?tubercular

DIC sec to sepsis -resolving

chronic kidney disease oh HD

dm2

anaemia, thrombocytopenia(improving 25k-40k)

P- rt feeds 

inj dexamethasone 8mg/iv/bd

inj meropenem 500mg/iv/bd

tab pcm 650mg/rt/sos

tab att- H-300mg,R-600mg,Z-1500 mg,E-900/RT/OD


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