80 M with altered sensorium

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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 competence in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan


CHEIF COMPLAINTS:

Fever since 10 days 

Burning micturition since 1 day

Left loin pain since 1 day 

Decreased urine output since 1day

Blood in urine since 3 hrs


HISTORY OF PRESENTING ILLNESS

A 80Yr male, agriculture by occupation,clinically presented to casualty with complaints of high grade fever since 10 days (25th sep - 5th oct) , not associated with cold / cough/abdominal pain.which was releived on taking antipyretics and oral antibiotics . Afterday10 of illness his fever subsided . After 3 days i.e he had symptoms of burning micturition, abdominal distention and left loin pain , non radiating, dragging type and decreased urine output having dark yellowish coloured urine since 1 day. 




PAST ILLNESS:

K/c/o : Hypertension since 1yr and taking medications irregularly 

Right lower end of tibial fracture 1 yr ago 

Not a K/c/o TB/asthma/CAD/CVD/epilepsy/ thyroid disorders


PERSONAL HISTORY:

80Yr male, married , agriculture by occupation, has normal appetite, mixed diet , regular bowels( not passed stools today), decreased urine output,no allergies, occasionally drinks ( once in a week) I.e (3.6 units of alcohol/week)

Smokes 10beedi/day (30 pack years)


No significant Family history


ON GENERAL PHYSICAL EXAMINATION 

Patient was drowsy , incoherent

GCS - E2( eye opening to pain)

            V2( verbal response- volcalises i.e                         makes sounds but no word)

             M3( motor response I.e abnormal flex     

ion to pain)

pallor present 

No icterus , cyanosis , clubbing, lymphadenopathy,edema


VITALS:  

On presentation 

Temp.-99.7

Bp- 120/90mmhg

PR-98bpm

RR-18cpm

Grbs-116mg/dl


  












SYSTEMIC EXAMINATIONS 

CVS: S1s2 heard

R/S : BAE+ , 

right infraxillary area crepts +

decreased breath sounds, 

P/A :scaphoid ,soft ,tenderness at umbilicus ,bowel sounds heard, stools passed yesterday 








COURSE IN HOSPITAL 

A 80Yr male came to casualty with above mentioned complaints. Upon arrival initial assessment was done. He was started on intravenous fluid therapy. Urine analysis and culture and sensitivity were sent . Urine analysis showed 10-1


febrile to touch 

GCS : E4V5M6

PR:142bpm

Bp:110/70mmhg

RR:18cpm

Pleural tap was done on 15/10/22


X-ray after pleural tap








TREATMENT:

1.IVF 3% NS @ 75ml/hr

2.INJ.MEROPENEM 500mg /IV /Bd for7 days

3. INJ.PAN40mg /iv/bd

4.inj. Tramadol 1Amp in 100ml Ns/iv/od

5.inj. NEOMOL 1gm 

6. Tab.dolo 650 mg/po/TID

7. Ryles  tube insertion 

8. Tab.  Azithromycin 500mg /po/od for 6 days

9. Inj. Vancomycin 1gm /iv/bd for 4 days

1st,3rd

2nd,4th 

X-ray on 16/10/22


Chest X-ray PA VIEW SUPINE POSITION TAKEN ON 17/10/22




Pleural fluid(EXUDATE)




Pleural fluid analysis- EXUDATE




Day 8
2nd time Pleural tap was done on 18/10/22



X-ray after pleural tap(2nd)

   
Patient developed pneumothorax 
Then after taking consent an ICD is placed in 5th ICS in mid axillary line



Fluid collected through ICD

( transudate)







Pleural fluid analysis:

Transudate






USG abdomen was done on 18/10/22




Ascitic Tap (diagnostic)was done on18/10/22
And sent for cytology, culture sensitivity, cell count





Day :9


S :  PAIN at site of ICD insertion, fever spike -yesterday 8pm 


O:

Pt c/c/c 

Bp - 110/70mmhg

PR - 110bpm

RR- 22cpm

Temp-98F

Spo2 - 92 at room air

CVS: S1S2+ loud s1@ aortic  and pulmonary area

apex beat at left 5th intercoastal space extended lateral to MCL

RS: BAE+

Inspection: Respiratory movements slightly more on right compared to left chest 

Crowding of ribs present

ICD- @ 5th Intercostal space @ mid axillary  line

 CREPTS AT 

LEFT INFRAAXILLARY AREA, IMA,ISA

RIGHT ISA,IMA


P/A: SOFT,BS+,Tenderness on palpation around umbilicus , stools not passed-D1

CNS: HMF INTACT 

          NO FND 

Input : 2300ml

Output: 1200ml








DIAGNOSIS:


ALTERED SENSORIUM SECONDARY TO ?HYPONATREMIA (resolved)- 

WITH CAP (RIGHT UL ANT LEFT LUNG)

? SEPTIC ENCEPHALOPATHY -LEFT PYELONEPHRITIS ( resolving)

WITH PRE RENAL AKI

with MICROCYTIC HYPOCROMIC ANEMIA SECONDARY TO  ?IRON DEFICIENCY 

? ANEMIA OF CHRONIC DISEASE 

WITH LEFT EMPYEMA 

WITH PNEUMOTHORAX WITH ICD DAY1

with k/c/o COPD and HTN 


 Treatment 


1)ALLOW ORAL FEEDS

2)IVF -NS/RL  @50ml/hr 

3) TAB. MIRTRAZAPINE 7.5mg/PO/HS

4)INJ. MEROPENEM 500 MG IV/BD (D10)

5) INJ. PAN 40MG IV/OD

6) INJ. TRAMADOL 1 AMP IN 100ML NS/IV/OD

7) INJ. VANCOMYCIN 1Gm/IV/BD(D7)

8) TAB. DOLO 650MG PO/ TID If temp.> 100F

9) NEB WITH DUOLIN 6th HOURLY and BUDECORT 8tH HOURLY 

10)VITAL + I/O CHARTING HOURLY 

11)ICD care 

bag always below waist 

Cap always open 

Check air coloum movement 

Maintain under water seal 

12)O2 inhalation with 2-4 lit


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