39 YEAR OLD MAN WITH ALTERED SENSORIUM WITH KIDNEY DISEASE

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I have 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 diagnosis and treatment plan.

 

A 39 Yr old male , electrician by occupation, resident of nalgonda,came to causality on 09/11/21 with..

CHEIF COMPLAINT:

Fever(10days back), loss of appetite(2days back) ,Involuntary movement of upper limbs and drowsiness(1day back)

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 days back then he developed  low grade fever with chills intermittently and nausea.And he also had cough but no discharge.

 -Loss of appetite since 2 days .

Since one day ,pt was unable to speak. but understanding commands .

Since yesterday morning(8/11/21) , patient was having 2 episodes of involuntary movements of b/l upper limbs and was drowsy since morning .

Left leg has slight swelling from the date of admission and it is progressive

No h/o of headache, blurring of vision, vomiting.

No h/o loose stool.

All his medical history started 8 month's ago 

8 months ago with the c/o low back ache , pain abdomen went nalgonda hospital,where incidently detected with creatinine level 5mg/dl.and diagnosed as RENAL CALICULI WITH INCREASED SERUM CREATININE .

His urine output was good and he had no pedal edema or sob. He was told to have renal failure and was on medication since then.

He even had h/o wt loss and loss of appetite and low grade fever. 

He was having intermittent back pain since then .

After 2 months in August ,

** August last week , 2021 -- c/o left lower limb weakness, slow gradually progressed to right LL -- B/L Paraplegia i .e flaccid paraplegic- MRI was done --and  they diagnosed as POTTS SPINE

Used ATT for 15 days and stopped , due to nausea and loss of appetite, patient was bedridden since, then and used unani medication.

Pt was neglected and using Unnani medications inspite of advising to use ATT.

**H.D was adviced 2 months ago - but didn't get it done due to fear of death ( among relatives deaths on H.D+)

** Since September 2021--Bed sores developed,  1 daily dressing done ,but patient was active and talks to everyone.

N/o h/o DM , HTN, EPILEPSY, ASTHMA.

PERSONAL HISTORY:

** He has normal appetite , consumes mixed diet with regular bowel movements, he was on Foley's since 6 months .

Sleep-adequate

No addictions

FAMILY HISTORY: his sister and uncle had kidney disease.

O/E :-

Pallor+

No icterus, cyanosis, clubbing edema , lymphadenopathy.

Pedal edema on left leg which pitting type.

VITALS ON ADMISSION:- 

Temp:- 101F 

PR:- 92 BPM

RR:-14 cpm

BP: 90/60 MMHG

Spo2:- 83 % at RA

GRBS:- 195 MG%

CVS:- S1 S2+ ,NO MURMUR

RS:- BAE+ , NVBS+

P/A SOFT ,NT

CNS:- Eye opening to pain

 No verbal  response

No meningeal signs(brudzinski sign and kernig's sign both are negative)

GCS:- E2 V1 M5. 8/15

PUPILS--B/L mid dilated unequal(Rt>Lft)

Plantars-- B/l Flexion 

Power- --.      RT.       LT

 Upper limb - 5/5.    5/5

 Lower limb- plegia plegia(0/5)

Tone --

 Upper limb- Increased.Increase

 Lower limb- Decreased.decreased.

Reflexes:-  RT.             LFT

            B-    absent.      2+

            T-.     3+.             3+

            S-.      2+.           2+

            K-.      Absent.   Absent

            A-.       Absent.    Absent.

Provisional diagnosis:- 

1) ALTERED SENSORIUM

2)SECONDARY TO? POST ICTAL CONFUSION WITH ? ACUTE ISCHEMIC CVA( PARIETO TEMPORAL AREA) . or ? uremic encephalalopathy.

3) ? TB - VASCULITIS/ SEPTIC INFARCT

4) PARAPLEGIA SECONDARY TO POTTS SPINE 

5) CKD

6) ANEMIA

7) GRADE 3 BED SORE.

Investigations:-

HB:- 3.8

PLT :- 61000

BGT:- A Positive

Na-137

K-4.3

Cl-98

Sr.creat-4.2

LFT:-

TB- 0.92

DB-0.27

SGOT-18

SGPT-24

ALP-375

TP- 4.7

ALBUMIN:-2.0

A/G :-0.76

LDH:- 225

Blood urea- 247

Rbs-143

Serology--NEGATIVE

C-reactive protein-- POSITIVE-2.4 mg/dl.

TREATMENT :-

1) IVF NS-2 units 

           RL-1 unit 

           Dns- 1 unit @ 100 ml/hr

2) Inj. Optineuron 1 amp in 100 ml NS  IV OD 

3) Inj. Levipil 1 gm IV stat--500 mg iv bd

4) RT Feeds milk + Protein powder 4th hourly..free water 200 ml 4th hourly

D1-5) Inj. Ceftriaxone 2gm iv bd

6) Inj. Neomol 1 gm IV SOS

7) Tab. Dolo 650 mg RT TID

8) Inj. Pantop 40 mg IV OD

9) ATT According to renal clearance and wt.

10) GRBS 12 TH HOURLY 

I/O CHARTING

BO/PR MONITORING.

11) INJ. Pan 40 mg /Iv /Od

12) Inj. ZOFER 4 mg iv bd.

12/11/21

They suspect the DVT ON LEFT LEG BECAUSE IT HAS SWOLLEN.

13/11/21

He get dialaysed after that he had better senoruim .

18/11/21

Patient had increased requirements of inotropes to maintain since 6pm 

No episode of tachypnea.

No response to verbal and painful stimuli.

19/11/21

At 6:15am patients saturation was not recorded with absent central pulses,8cycles of cpr was done as per 2020aha guidelines,but he couldn't be resuscitated.