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A 72 year old female in a drowsy state

A 72 year old female home maker since 10-15 years (farmer by occupation), resident of Narammagudem, came to casuality in a drowsy state.

Daily routine: Patient was a farmer by occupation, but presently she discontinued working and is a homemaker. She gets up at 7:00 am in the morning, finishes her chores, has lunch at around 1:00 pm and takes rest, gets up and continues her daily activities, sleeps by 10:00 pm

History of present illness: 

  • Patient was apparently asymptomatic 10 years back ,then patient had h/o fall for which she went to local hospital where she got diagnosed with Diabetes mellitus and since then she is on OHA medication (glim m2)
  • 4 years back she had h/o fall and went to hospital and got diagnosed with HTN.
  •  1 session of dialysis was done (indication/cause unknown)
  • 1 month back she developed hypoglycaemia, secondary to OHA’s ,which was resolved later.
  • Patient had h/o fall 4 days back ,diagnosed as intertrochanteric fracture of femur of right leg, which was operated (CRIF done).
  • On POD 2, patient was drowsy ,opening eyes to deep pain. 
  • 3 episodes of non- projectile, bilious vomitings associated with abdominal distension and on/off fever two days ago, on POD 3

PAST HISTORY: 

K/C/O DM since 10 years  on medication.

K/C/O HTN since 4 years on medication

No history of CAD, CVA, TB , ASTHMA, EPILEPSY 

GENERAL EXAMINATION: 

O/E : Patient is responding to vocal commands

Pallor - present




Icterus -absent

Cyanosis - absent

Edema of feet - present

Lymphadenopathy - absent

Clubbing - absent



VITALS:- 

 BP: 120/90mmhg

 PR: 98 bpm 

 RR: 25cpm 

 Spo2: 95%

 Grbs: 139



SYSTEMIC EXAMINATION : 

CARDIOVASCULAR SYSTEM :

 S1 and S2 heard, no murmurs heard 

RESPIRATORY SYSTEM : BAE present

P/A : soft 

CNS: 

1) HMF - INTACT 

2)MOTOR SYSTEM : 


                      Right     Left


Bulk: 

Inspection.  N              N

Palpation.    N              N


Tone: 

UL.              N                N


LL.              N                 N


Upper Limb:


Shoulder:

Flexion.     5/5        5/5

Extension. 5/5.       5/5 

Abduction: 5/5.      5/5 

Adduction: 5/5.      5/5 


Elbow: 

Flexion (biceps)     5/5.        5/5 

Extension (triceps) 5/5.       5/5


Lower Limb:

Ilio psoas.            ---       5/5

Gluteus max.      ---        5/5

Adductor femoris.  ---     5/5

Hamstrings.             ---     5/5

Quadriceps.             ---        5/5

Tibialis ant.               5/5     5/5

Tibialis post.              5/5    5/5

Ex. Digitorum L.       5/5    5/5 

Fl. Digitorum L.        5/5    5/5

Ex. Hallucis L.          5/5     5/5


Deep tendon reflexes:

Biceps:                       +2 +2

Triceps:                     +2 +2

Supinator:.                +2 +2

Knee:                          +2 +2

Ankle:                         +2 +2

Plantar: flexor

Sensory:

Crude touch. + +

Pain. + +

Temp. + +

Fine touch. present

Vibration. + +

Position. + +

CRANIAL NERVES : Intact

Cerebellar signs : Normal

INVESTIGATIONS:

On 12/2/22 :

Day 1


D dimer: 6910ng/ml

Sr creatinine: 5.0

BGT: B POSITIVE

Blood urea : 143

ESR :. 140

RBS: 220

APTT: 30 seconds

PT : 15 seconds

INR: 1.11




ECG:



Venous doppler of right lower limb: 

No evidence of any DVT

Subcutaneous edema present 

USG ABDOMEN:

Raised echogenecity in both kidneys.

Multiple small calculi in Gallbladder.

On 13/2/22:

Day 2





On 14/2/22:

Day 3






On 15/2/22:
Day 4





On 16/2/22:
Day 5




CT abdomen:

No abnormality detected in abdomen

No features of S/O obstruction

Left sided kidney is small


PROVISIONAL DIAGNOSIS:

? Uremic encephalopathy with pre renal AKI with POD 4 right femur fracture ? CRIF + PFM with DM and HT

TREATMENT

On 12/2/22:

1. INJ. Lasix 40mg IV/BD

2. INJ. HAI SC/TID 

3. INJ. CEFTRIAXON 1g/IV/BD

4. INJ. CLINDAMYCIN 600mg/ IV /TID

5.INJ. CLEXANE 20 mg SC/OD

6. INJ. OPTINEURON 1 AMP in 100 ml NS /IV/OD

7.TAB. Amlong 10mg PO /OD

8.IVF NS UO + 30 ml/hr

On 13/2/22:

1. INJ. Lasix 40mg IV/BD

2. INJ. HAI SC/TID 

3. INJ. CEFTRIAXON 1g/IV/BD

4. INJ. CLINDAMYCIN 600mg/ IV /TID

5.INJ. CLEXANE 20 mg SC/OD

6. INJ. OPTINEURON 1 AMP in 100 ml NS /IV/OD

7.TAB. Amlong 10mg PO /OD

8.IVF NS UO + 30 ml/hr


On 14/2/22:

TEMP:- 101 F 

PR:- 92bpm

BP:- 140/ 60mmhg

GRBS: 123MG/DL

CVS:- S1S2 heard , no murmurs

RS : BAE present

P/A:- GUARDING PRESENT

I/O: 2400/2600

Stools : not passed

Treatment:

INJ. MONOCEF 1GM/IV/BD

INJ. LASIX 40 MG IV/BD

INJ. HAI SC/TID 

INJ. CLINDAMYCIN 600mg/ IV /TID

INJ. CLEXANE 20 mg SC/OD

TAB. Amlong 10mg PO /OD

IVF NS UO+ 30ML/HR



On 15/2/22:

TEMP:- 98.4 F 

PR:- 96 bpm

BP:- 150/ 90mmhg

GRBS: 245MG/DL

CVS:- S1S2 heard , no murmurs

RS : BAE present

P/A:- GUARDING PRESENT

I/O: 2100/3200

Stools : passed 

Treatment:

INJ. MONOCEF 1GM/IV/BD

INJ. LASIX 40 MG IV/BD

INJ. HAI SC/TID 

INJ. CLINDAMYCIN 600mg/ IV /TID

INJ. CLEXANE 20 mg SC/OD

TAB. Amlong 10mg PO /OD

IVF NS UO+ 30ML/HR

INJ ERYTHROPOIETIN 4000 IU/SC/WEEKLY ONCE

On 16/2/22

INJ. MONOCEF 1GM/IV/BD

INJ. PIPTAZ 9.5 MG/ IV

INJ. LASIX 40 MG IV/BD

INJ. HAI SC/TID 

INJ. CLINDAMYCIN 600mg/ IV /TID

INJ. CLEXANE 20 mg SC/OD

TAB. Amlong 10mg PO /OD

IVF NS UO+ 30ML/HR



On 17/2/22:


POD 8:

RIGHT IT FEMUR #

ORIF+PFN Done 

On examination:

Pt is C/C/C

Abdominal pain - reduced

BP- 120/90 mmHg

PR- 96bpm

3 sessions of hemodialysis done

Hemogram:

Hb-7.3

TLC - 29,000

PLT- 1.5

D- DIMER - 3280

RFT

UREA - 66

SERUM CREATININE- 2.3

URIC ACID-4.6

Ca- 8.8

PO4 - 4.2

Na-139

K- 3.3

Cl- 90

I/o - 2400/3000ml 

Treatment:

INJ: PIPTAZ 9.5 MG / IV

INJ. LASIX 40 MG IV/BD

INJ. HAI SC/TID 

INJ. CLINDAMYCIN 600mg/ IV /TID

INJ. CLEXANE 20 mg SC/OD

TAB. Amlong 10mg PO /OD

IVF NS UO+ 30ML/HR

On 18/2/22:

POD 9:

Right IT femur fracture, CRIF + PFN DONE with DM + HTN

3 Sessions of hemodialysis done.

Vitals:

O/E 

Pt is C/C/C 

Abdominal pain and suprapubic pain is present

Afebrile

BP- 140/100 mm of Hg

PR: 90 bpm

CVS: S1 S2 +

Respiratory system: BAE+

PER ABDOMEN : Soft and tender

Grbs : 8Am - 223mg/dl

I/O: 1700/2100 ml

Treatment:

INJ: PIPTAZ 9.5 MG / IV

INJ. LASIX 40 MG IV/BD

INJ. HAI SC/TID 

INJ. CLINDAMYCIN 600mg/ IV /TID

INJ. CLEXANE 20 mg SC/OD

TAB. Amlong 10mg PO /OD

IVF NS UO+ 30ML/HR

Inj Erythropoietin 4000IU/ SC / weekly once

BP , PR, SPO2, temperature monitoring.




















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