45M with Fever, slurring of speech

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45M came to casuality now with 

C/O fever since 5 days  

Burning micturation since 3 days

slurring of speech since 1 day.  

Patient was an elite farmer who used to work in feilds daily from 8am to 6pm with few breaks for lunch and short naps 

Pt was apparently alright 2 years back where he was first time hospitalised for the complaints of fever which is high grade associated with chills associated with burning micturation but not associated with vomitings and pain abdomen where diagnosed with Diabetes and advised with Insulin. Later on subsequent follow up he was advised with both Insulin and OHAs. 

Now patient has fever since 4-5 days with burning micturation since 3 days and slurring of speech since 1 day.

Skipped OHA yesterday due to feeling of generalised weakness. 

H/o hospital admission for fever and diagnosed with DM 2 yrs back.

Personal history: 

Sleep disturbed since 2 days

Appetite lost

Bowel and bladder movements normal

Patient is a chronic alcoholic since with a daily intake of 90-180 ml of whisky everyday after his feild work.

General examination:

Thin built and malnourished ( cachexic)

Mosquito bites seen on both UL 

Which are not blanchable

Pallor: present 

Icterus: absent 

Cyanosis : absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : absent 

Vitals:

 Temperature: afebrile 

 Pulse: 90bpm

 Blood pressure:110/80 mm of hg

 Respiratory rate : 20 bpm

SpO2 : 98 on RA

GRBS : 570 MG/DL

Systemic examination:

Cardiovascular system  

JVP - not raised

Visible pulsations: absent 

Apical impulse : left 5th intercostal space in midclavicular line.

Thrills -absent 

S1, S2 - heart sounds heard 

Pericardial rub - absent

Respiratory system:

Patient examined in sitting position

Inspection:-

oral cavity- Normal ,nose- normal ,pharynx-normal 

Shape of chest - normal

Chest movements : bilaterally symmetrically reduced

Trachea is central in position.

Palpation:-

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 5th ICS, 

Chest movements bilaterally symmetrical 

AUSCULTATION 

B/L lungs clear 

Abdomen examination:

INSPECTION

Shape : distended 

Umbilicus: slit like

Movements :normal

Visible pulsations :absent

Skin or surface of the abdomen : normal 

PERCUSSION- shifting dull ness present.

AUSCULTATION :bowel sounds heard

CNS : 

E4V5M6

B/L Pupils NSRL

Hmf intact

Cranial nerves normal

Neck stiffness + 

kernigs +, 

B/L lower limb power 3/5,. Upper limb 4/5. 

All 4 Limbs normal.

Sensory system - pain, temp intact.

Based on clinical findings our clinical diagnosis was : 

Pyrexia 2to ?Viral/ ? bacteria

? Encephalitis 2to infection

Uncontrolled sugars

Labs : 

Diagnosis: 

Urosepsis with MODS 

Disseminated intravascular coagulation 2to sepsis

Dyselectrolytemia

Hypoalbumenemia

Uncontrolled sugars.

CSF analysis was planned but in view of derranged coagulation profile and severe thrombocytopenia Lumbar puncture was not done. 

Treatment : 

-I.V FLUIDS -NS , RL @100ml/hr

-INJ.MEROPENEM 500mg/iv/ BD

-INJ.FALCIGO /IV

-INJ.LASIX 20mg /IV/BD

-INJ. OPTINEURON 1amp. In 100ml NS/IV/OD

-INJ.PAN 40mg /IV/OD

-INJ. HAI S/C .TID ACC. TO GRBS 

-INJ.VIT K 10mg/SC/OD

-TAB. DOXY 100 mg /PO/BD

-TAB .DOLO650 /PO/SOS

-PROTEIN -X POWDER 1SCOOP IN 100ML MILK 

100ML FREE WATER PO/4th hrly

-ORS SACHETS in 1ltr water /PO/OD

-GRBS 7 point profile monitoring

-BP/PR / TEMP-4th hrly

Day 1 : 

Fever spikes +

Altered sensorium +

Vitals stable

GRBS: 290 mg/dl

I/O: 4350/2540 ml

Dx: Urosepsis with MODS

?DIC

Dyselctrolytemia (resolved)

DM-2 with uncontrolled sugars

Plan: conservative Rx

Day 3,4,

Patient sensoriu gradually deteriorated with GCS E2V2M4. With B/L Pupils NSRL. 

MRI brain was done which was normal except cortical atrophy.

Day 5 

In view of progressive rise in urea and altered sensorium patient was initiated on hemodialysis to clear off urea and toxins from blood.

Tab. Doxycycline stopped.

Post dialysis after 6-12h patient sensorium improved. Started walking.

Day 6,7,

Inj. Meropene stopped.

Alternate day dialysis was done with below dialysis prescription : 

UF - Nil

Flow rate - 250-300 ml/min

K+ correction ( as 3K cans are not available we gave 2 amp correction)

Time : 4 hrs.

Patient developed fever again and leucopenia, gradual elevated in ESR.

Day 8 

Patient had fever spikes and RR 24 cpm with decreased breath sounds on Rt ISA.

X ray showed Rt sided effusion.

In view of hospital aquried pneumonia patient was started in inj. Levoflox.

Day 9,10

Patient had low grade fever with improving leucocytes and platelets. Vitals stable.

Day 11. 

Patient has high grade fever ( 102F ) no SOB, vitals stable, RR 24cpm, spo2 94 on RA. 

Usg guided pleural tap was done. 

Reports awaited.