fever projr unclassified 75/M 202414540

 unclassified ; 20240350154

Diagnosis

TYPE II RESPIRATORYFAILURE SECONDARY TO ASPIRATION PNEUMONIA(RESOLVED)

UROSEPSIS(RESOLVED)

CHRONIC RENAL FAILURE SECONDARY TO DIABETIC NEPHROPATHY

CHRONIC ISCHEMIC STOKE (OLD LACUNAR INFARCTS IN STRIATOCAPSULAR, L THALAMUS, R CORONA RADIATA)

K/C/O T2DM SINCE 18 YEARS ,HTN SINCE 1 YEAR,CVA SINCE 9 YEARS

GRADE II BEDSORE OVER SACRAL REGION

Case History and Clinical Findings

C/O SOB SINCE 1 WEEK

C/O LOSS OF APPETITE SINCE 1 WEEK

HOPI-

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 WEEK AGO THEN DEVELOPED SOB INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE

C/O LOSS OF APPETITE SINCE 1WEEK

H/O LOOSE STOOLS 2-3 EPISODES WATERY FOR ONE DAY

H/O CONSTIPATION FOR 2 DAYS

H/O PYURIA 1 WEEK AGO

H/O EFT LOWER LIMB SWELLING SINCE 4 YEARS PITTING TYPE

H/O FRACTURE TO LEFT LOWER LIMB DUE TO HYPOGLYCEMIC EVENTS

H/O LOSS OF SENSATION IN BOTH FEET SINCE 10 DAYS

H/O BOTH UPPER LIMBS SENSATION ON AND OFF SINCE 1 WEEK

H/O THROAT PAIN SINCE 2 DAYS

H/O DIFFICULTY IN SWALLOWING FOR SOLIDS AND LIQUIDS SINCE 2 DAYS

NO H/O DECREASED URINE OUTPUT

NO H/O FEVER VOMITINGS ABDOMINAL PAIN

H/O SLURRING OF SPEECH SINCE 1WEEK

PAST HISTORY-

K/C/O DM SINCE 18 YEARS ON TAB GLIMIPRIDE 2 MG PO/OD

K/C/O HTN SINCE 1 YEAR ON TAB TELMA 20MG PO/OD

H/O CVA 9 YEARS AGO (LEFT HEMIPARESIS) tHROMBOLYSIS DONE

H/O CVA 1 YEAR AGO(LEFT HEMIPARESIS WITH DEVIATION OF MOUTH) USED AYURVEDIC MEDICATIONS AND PATIENT WAS BED RIDDEN FROM 6 MONTHS AND DEVELOPED BED SORE SINCE 2 MONTHS ON SACRAL REGION.

H/O TRAUMA TO LEFT HIP LEFT LEG OPERATED

H/O AMPUTATION OF LEFT 4TH AND 5TH TOES

K/C/O CKD SINCE 4MONTHS

N/K/C/O CAD EPILEPSY THYROID DISORDERS

ON EXAMINATION-

TEMP- AFEBRILE

RR 28 CPM

BP-100/60 MM HG

PR 76BPM

SPO2 92% @RA 100% @1L O2

GRBS-96MG/DL

I/O-850/800

CVS - S1S2 HEARD,NO MURMURS

RS - BAE PRESENT DIFFUSE GRUNTING PRESENT.

P/A - SOFT ,NON TENDER NO ORGANOMEGALY BOWEL SOUNDS PRESENT

CNS

E4 V4 M 6

PATIENT IS CONCIOUS COHERENT COOPERATIVE

POWER RIGHT LEFT

UL 4/5 3/5

LL 3/5 1/5

TONE

UL NORMAL NORMAL

LL NORMAL NORMAL

REFLEXES B T S K A P

RIGHT 2+ 1+ - + - F

LEFT 2+ 1+ - + - F

CORNEAL CONJUCTIVAL BILATERALLY PRESENT

GAG PRESENT

MENINGEAL SIGNS ABSENT

COURSE IN THE HOSPITAL:

75 YEAROLD MALE WHO IS KNOWN CASE OF DM II SINCE 18 YEARS,HTN SINCE 1 YEAR, CKD SINCE 1 YEAR, CVA AND GRADE III BED SORE WAS BROUGHT TO CASUALITY ON 31/03/24 AT 2.56PM WITH CHIEF COMPLAINTS OF LOSS OF APPETITE , SOB, DIFFICULTY IN SWALLOWING SINCE 10 DAYS,PATIENT WAS DROWSY BUT ORIENTED TO TIME, PLACE AND PERSON.ROUTINE INVESTIGATIONS WERE DONE AND FOUND TO HAVE RAISED CREATININE, UREA, AND HYPERKALEMIA.PATIENT WAS ON RYLE'S FEEDS , FOLEY'S CATHETHERISATION WAS DONE AND STARTED ON ANTIBIOTIC INJ.PIPTAZ 4.45 GM IV STAT FOLLOWED BY 2.25 GM IV BD AND PLANNED FOR HEMODILAYSIS.RIGHT FEMORAL CENTRAL LINE WAS PLACED ON 31-3 - 24 AND TAKEN FOR DIALYSIS WITH 1 PRBC TRANSFUSION, OPTHALMOLOGY OPINION WAS TAKEN ON 31-3-2024 BUT AS PATIENT WAS NOT COOPERATIVE FUNDOSCOPY COULD NOT BE PERFORMED . SURGERY OPINION WAS TAKEN IN VIEW OF BED SORE ON SACRAL REGIONN AND THEY ADVISED POSITION CHANGE 2 ND HOURLY , REGULAR ASEPTIC DRESSING .ON 2-4-2024 AND 3-4-2024 PATIENT WAS TAKEN FOR DIALYSIS WITH 1 EACH PRBC TRANSFUSION, AS PATIENT GCS NIS DETORIATING CT BRAIN WAS DONE ON 5 4 - 24 SHOWING OLD LACUNAR INFARCTS IN RIGHT STRIATOCAPSULAR REGION , LEFT THALAMUS , RIGHT CORONA RADIATA AND CHRONIC SMALL VESSEL ISCHEMIA AND DIFFUSE CEREBRAL ATROPHY .ON 6-4-2024 PATIENT WAS TAKEN FOR 4 TH SESSION OF DIALYSIS, POST DIALYSIS HE SUDDENLY HAD FALL IN SATURATION AND FALL IN GCS TO E1V1M1 AND WAS INTUBATED WITH ABG SHOWING TYPE 2 RESPIRATORY FAILURE .HE WAS ON MECHANICAL VENTILATOR FOR 5 DAYS AND WAS MAINTAINING STABLE VITALS HE WAS THEN CHANGED FROM AC MV TO SIMV MODE AND THEN TO CPAP-VC MODE, AND THEN PATIENT WAS SHIFTED TO T-PIECE WITH 6L O2 AND AFTER WATCHING SERIAL ABGS AND THERE IS IMPROVEMENT IN GCS FROM E1V1M1 TO E4V4M6 PATIENT WAS EXTUBATED AFTER SATISFYING THE EXTUBATIONCRITERIA, ON 11/04/24 5TH SESSION OF HD WASDONE 12/4/24.

PATIENT IS REQUIRING O2 SUPPORT OF 1L, ADVSIDED FOR HOME OXYGENENATION.

Investigation

RFT 31-03-2024 03:20:PMUREA 190 mg/dlCREATININE 8.9 mg/dlURIC ACID 9.3 mmol/LCALCIUM 7.9 mg/dlPHOSPHOROUS 6.2 mg/dlSODIUM 138 mmol/LPOTASSIUM 6.1 mmol/L.CHLORIDE 106 mmol/L

LIVER FUNCTION TEST (LFT) 31-03-2024 04:47:PMTotal Bilurubin 0.60 mg/dlDirect Bilurubin 0.18 mg/dlSGOT(AST) 154 IU/LSGPT(ALT) 159 IU/LALKALINE PHOSPHATASE 222 IU/LTOTAL PROTEINS 4.9 gm/dlALBUMIN 2.16 gm/dlA/G RATIO 0.79

ABG 01-04-2024 05:12:AMPH 7.20PCO2 47.7PO2 81.1HCO3 18.1St.HCO3 17.2BEB -8.8BEecf - 8.4TCO2 40.4O2 Sat 94.4O2 Count 10.8

RFT 02-04-2024 11:45:PMUREA 92 mg/dlCREATININE 5.6 mg/dlURIC ACID 5.1 mmol/LCALCIUM 8.1 mg/dlPHOSPHOROUS 4.1 mg/dlSODIUM 143 mmol/LPOTASSIUM 4.4 mmol/L.CHLORIDE 106 mmol/L

RFT 05-04-2024 03:27:AMUREA 89 mg/dlCREATININE 5.3 mg/dlURIC ACID 5.0 mmol/LCALCIUM 8.3 mg/dlPHOSPHOROUS 4.6 mg/dlSODIUM 144 mmol/LPOTASSIUM 3.9 mmol/L.CHLORIDE 104 mmol/L

ABG 31-03-2024 03:20:PMPH 7.205PCO2 31.4PO2 53.3HCO3 11.9St.HCO3 12.9BEB -14.5BEecf - 14.4TCO2 27.4O2 Sat 86.4O2 Count 6.7

COMPLETE URINE EXAMINATION (CUE) 31-03-2024 04:47:PMCOLOUR Pale yellowAPPEARANCE CloudyREACTION AcidicSP.GRAVITY 1.010ALBUMIN ++++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS PlantyEPITHELIAL CELLS 1-2RED BLOOD CELLS 5- 6CRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

RFT 01-04-2024 05:12:AMUREA 141 mg/dlCREATININE 6.8 mg/dlURIC ACID 6.9 mmol/LCALCIUM 8.7 mg/dlPHOSPHOROUS 5.4 mg/dlSODIUM 144 mmol/LPOTASSIUM 4.8 mmol/L.CHLORIDE 101 mmol/L

RFT 04-04-2024 07:43:AMUREA 80 mg/dlCREATININE 4.7 mg/dlURIC ACID 4.6 mmol/LCALCIUM 8.2 mg/dlPHOSPHOROUS 3.9 mg/dlSODIUM 145 mmol/LPOTASSIUM 3.9 mmol/L.CHLORIDE 106 mmol/L

SEROLOGY - NEGATIVE

USG WAS DONE ON 31/3/24

IMPRESSION-

CHOLELITHIASIS

B/L PLEURAL EFFUSION WITH UNDERLYING LUNG COLLAPSE

B/L KIDNEY SHOW GRADE II RPD CHANGES WITH B/L RENAL CORTICAL CYSTS

ET TUBE CULTURE WAS SENT

ENTEROBACTER SPECIES WAS DETECTED

2D ECHO REPORT:

NO RWMA

CONCENTRIC LVH+

GOOD LV SYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION

MILDLYDILATED RA/LA

MODERATE TR+ WITH PAH

RVSP:40+10=50MMHG

MILD AR+

TRIVIAL MR+

MINIMAL PERICARDIAL EFFUSION+

MAC+, THICKENED AV+

IVC-1.9CMS, DILATED, NON COLLAPSING

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION< 1.5L/DAY

SALT RESTRICTION <2G/DAY

RT FEEDS -50ML MILK 2ND HOURLY, 100ML MILK WITH PROTIEN POWDER 4TH HRLY

INJ.PIPTAZ 2.25GMS IV BD X 10DAYS

INJ.CLINDAMYCIN 600MG IV/BD X 5DAYS

INJ.MONOCEF 1GM IV/BD FOR 3 DAYS

INJ.LASIX 40MG IVBD

INJ.EPO 4000 IU S/C ONCE A WEEK

INH.IRON SUCROSE 200MG IN 100ML NS/IV DURING DIALYSIS

INJ HUMAN ACTRAPID INSULIN S/C TID BEFORE MEALS ACC TO GRBS

TAB NODOSIS 500MG RT/BD

TAB SHELCAL-CT RT/OD

TAB OROFER-XT RT/OD

NEBULIZATION WITH DUOLIN , BUDECORT- 6TH HOURLY

TAB TELMA 40 MG RT/OD

Advice at Discharge

RT FEEDS -50ML MILK 2ND HOURLY, 100ML MILK WITH PROTIEN POWDER 4TH HRLY

FLUID RESTRICTION< 1.5L/DAY

SALT RESTRICTION <2G/DAY

TAB.TAXIM 200MG RT OD FOR 5 DAYS

TAB.CLINDAMYCIN 300 MG RT BD FOR 5 DAYS

TAB LASIX 40 MG RT BD

TAB NODOSIS 500MG RT/BD

TAB SHELCAL-CT RT/OD

TAB OROFER-XT RT/OD

TAB TELMA 40 MG RT/OD

INJ.EPO 4000 IU S/C WEEKLY ONCE

NEBULIZATION WITH DUOLIN , BUDECORT- 6TH HOURLY

FREQUENT POSITION CHANGE

AIRBED

ASEPTIC DRESSING OF BEDSORE.