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:
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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