75 F with altered sensorium

 January 10, 2023

I’ve 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


75 year old women came to causality on 10/01/23 with 
C/o SOB since last night
 cough since 15days 
Fever since yesterday evening 
K/C/O cellulitis - surgery done 20 days back

HOPI:
Patient was apparently asymptomatic 3 years ago and then developed minor abrasion to right lower limb and then developed right lower limb swelling till knee and was diagnosed to be having right lower limb cellulitis and fasciotomy was done and resolved after 2 months and at the time dm was diagnosed and kept on medication.she was normal from then and 20 days back she developed sudden swelling of left lower limb till knee intially and then progressed to thigh.she went to local hospital and found to have left lower limb cellulitis and on further evaluation found to be having erosion of knee and was diagnosed septic arthritis and incision and drainage was done and left knee osteotomy was done , fasciotomy and debridement of left lower limb was done.20 pRBC'S transfusions was done and daily dressing was done.since 5 days she developed fever which was incidious in onset,high grade,with chills and rigor.she developed SOB since 3 days and also was on altered sensorium since 3 days.
No urine output since yesterday night for which Foleys catheter was placed today morning and she is passing urine now.
PAST HISTORY:
K/C/O DMT2 on Tab zorylmv1(metformin 500 mg +glimeperide 1mg+ voglibose 0.2mg) since 3  years.
Not a K/C/O HTN/asthma/TB/Epilepsy/CAD/CVA/Thyroid disorders.

MENSTRUAL HISTORY:
Age of menarche: 13 years
Age of menopause: 50 years

PERSONAL HISTORY:
Appetite: normal. 
Diet: mixed
Bowel and bladder: regular
Sleep: adequate
Addictions: no addictions

GENERAL EXAMINATION:
Patient is drowsy but arousable.
Pallor: present
Icterus:abesnt
Cyanosis:absent
Clubbing: absent 
Lympadenopathy:absent
Edema:absent

VITALS: 
Temp: 97.7F
Bp:120/70mmhg
PR:90bpm
RR:16cpm
Spo2:97
GRBS:211mg/dl

SYSTEMIC EXAMINATION:
Respiratory- B/L air entry present; diffuse wheeze present 
CVS- s1s2+ no murmur 
P/A soft non tender 
CNS- patient is drowsy
PERSONAL HISTORY:
Appetite: normal. 
Diet: mixed
Bowel and bladder: regular
Sleep: adequate
Addictions: no addictions

INVESTIGATIONS:

On 10/01/23
ECG on 10/01/23
ECG on 12/01/23
ECG on 13/01/23


Diagnosis:
Altered sensorium decrease evaluation 
Encephalopathy secondary to left lower limb  cellulitis with ? Septic arthritis in left knee.
 k/c/o DMT2
P
1. Iv fluids NS and RL @ 75ml/hr
2.inj.Mnocef 2gm iv/bd
3. Inj. Pan 40mg IV/OD
4. Inj. Noemal 1gm/IV/SOS
5.Inj. Zofer 4mg/IV/OD
6.inj.optineuron 1amp in 10ml NS/IV/OD
7.syrup.Ascoryl-  /RT/BD
8.RT feeds - 50ml milk 4th hourly
                      100ml water 2nd hourly
9.NEB with Budecort and Duolin 6th hourly
10.left lower limb elevation
11.Grbs monitoring 70 profile


ON 13th January

S
Pt c/o shortness of breath 
Fever subsided
Productive cough with expectoration 15days 
Stools passed

O
Patient is concious coherent oriented to person and place not oriented to time
Temp-97.7F
BP-130/70mmhg 
PR-120bpm 
CVS- s1s2 heard ; no murmurs 
RS-b/L air entry present ; diffuse wheeze present
CNS- patient is drowsy
GCS-E2V2M4
P/A-soft and non tender
  
Hb-8.2
TLC-17800
RBC-2.9million 
Pcv24.8
S urea:74
S Cr:1.5
Na-135
K-3.8
Cl-98
Ica-0.70

TB-0.80
DB-0.19
AST-20
ALT-10
ALP-307
T.pro-6.5
Alb-2.0
A/G-0.45
FBS-163
PLBS-351
HBA1C-7.5
R.C-2.3
Absolute reticulocyte -1.4
Ret.index:0.68

A
Altered sensorium (resolving)  secondary to left lower limb  cellulitis with left knee Septic arthritis with diabetic mellitus type 2 with anemina under evaluation 
Right heart failure secondary toCOPD
With s/p: left nee aspiration on 10/12/23and lumbar puncture on 11/12/23
 

P
1.RT feeds- 50ml milk with protein powder and 100 ml water 2nd hourly 
2.inj.meropenem 500mg/iv/BD
3.inj.vancomycin 1gm/iv/BD
4. Inj. Pan 40mg IV/OD
5.Inj. Zofer 4mg/IV/OD
6.inj.human Actrapid insulin/SC/TID
7.inj.vitK 1amp in 100mlNS/IV
8.inj Lasix 20 mg/IV/BD
8.Dolo 650mg /RT/TID
7.syrup.Ascoryl-LS /RT/TID
9.NEB with Budecort and Duolin 6th hourly
10.left lower limb cellulitis
11.Grbs monitoring 70 profile
12.bp temp monitoring 2nd hrly

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