57M fever, blurring of vision, left sided weakness

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

57 M came to casualty with c/o generalised weakness since 1 month ,fever since 1 week,altered sensorium since 3 days.

HOPI:

Since 1 month he has been complaining of generalised weakness. Since 15 days he has been feeling cold(even though it is summer) and has been switching off all the fans in the house. 

He has been suffering with constipation since 10 days. Has not passed stools at all(confirmed by the attender) He did not take any medication for it

He also complained of abdominal distension/bloating due to not passing stools.

Since 1 week he has fever insidious in onset gradually progressive, high grade. Associated with body pains.Not Associated with chills and rigor. Not relieved with medication.Not associated with nausea, vomiting, burning micturition, headache.

Since 3 days -he fell in the washroom two times(on 22/5/1023)and was not able to get up. When his family members found him, he had slurring of speech and altered sensorium.They took him to the Nalgonda government hospital.

There they gave him an enema and his constipation and bloating was relieved immediately.

They also treated him symptomatically. But he was still in altered sensorium and did not cover

They then shifted him to a private hospital as they had contacts there. There they did MRI and found that infarct in the cortical and subcortical regions of occiput.

but due to too expensive in that hospital so after tracheostomy in view of low GCS (24/05/23 morning) they came to our hospital. On the way in the ambulance, he was able to recognise his family. They brought him to the casualty .

On 30/5/2023: 

He developed scrotal swelling at afternoon.

Surgery referral taken:

On P/A examination:

Crepts + ,over abdomen wall b/l lateral aspects extending upto upper 1/3 rd aspects rt thigh and 2/3 rd of lt thigh.

L/E : scrotal edema + , no local raise of temp. Tenderness can't be elicited. 

Scrotal skin rugocities absent.

Creptations + in scrotum on palpation.

No fluctuation,get above the swelling+.

Diagnosis- surgical emphysema.

Advised - no surgical intervention needed. Emphysema will resolve spontaneously.if persists then plan for skin Nick's.

He developed SOB, sudden in onset,grade 4 MMR, orthopnea present , No PND.

Pulmonology refferal was taken I/v/o sob and fall in saturations,tachycardia and tachypnea.

Pt. Is connected to the mechnical ventilation i/v/o fall in saturation,tachypnea and tachycardia. 

They advised chest x ray - 

chest x ray PA view showed pneumothorax.

 On percussion- hyperresonant .

Needle thoracocentesis was immediately started than ICD was placed at 5 th ICS.

On 10/6/2023: 

repositioning of ICD was done.

On15/6/2023:

Blood transfusion was done.

O 16/6/2023: 

C/o suprapubic bulge from Night onwards.

Urology referral was taken:

On P/A soft, tenderness+ in all quadrants of abdomen. Suprapubic tenderness +.

Foley's Insitu. Scrotum normal.

Advised USG abdomen

InPast history

In 2019 end of the year- He has felt "weak" . One fine day he fell down(due to low energy) while cycling and was immediately rushed to the hospital. They told him his cervical nerves got compressed and said he needed surgery. But due to family issues, he didn't get surgery then, and got it done after 2 months( cervical spondylosis surgery). He recovered after 6 months and started walking with support of a stick since then. The doctors then discovered he had problems in the lumbar region as well (4 years back) and needed surgery too, but didn't give consent for that surgery as they told him he would never be able to walk.

H/o htn since 4 years using medication irregularly

N/k/c/ DM, asthma, epilepsy, thyroid, CAD

Personal history: 

Diet-mixed

Appetite - normal

Sleep - adequate

Bowel and bladder - bowel (constipation),bladder normal.

Addiction - drinks toddy occasionally

General Examination:

Patient is C/C/C

Moderately build and nourished.

No pallor,icterus,cynosis,clubbing, lymphadenopathy,pedal edema.

Vitals

Temp 101F

Bp -130/90 mmhg

Pr -102 bpm

Rr - 20 cpm

Spo2 100% on 4 liters of RA

Systemic examination:

CNS: 

GCS- E4 V (NT) M6

Power - 

         Rt. Lt

UL - 4/5 4/5

LL - 3/5 3/5

TONE 

UL - N. N

LL - N. N

Reflexes

B - 3+. 3+

T - 3+. 3+

S- 2+. 2+

K - 2+. 2+

A - 1+ 1+

Plantar - extension of big toe in both limbs

RS- bilateral air entry present

Bilateral infra axillary coarse crepts

       NVBS

Decreased movements on left infrascapular region

CVS- S1s2present, no murmurs heard

PA- soft and non tender.

 

PROVISIONAL DIAGNOSIS:

CVA with Acute ischemic stroke (infarct in right occipital lobe ) with Hyponatremia (resolved) with AKI on CKD (resolved) with k/c/o HTN since 3 yrs.

Investigations

24/5/2023:-

CUE-

Albumin:++

Sugar. - nil

Pus cells- 1-2 

Epithelial cells -1-2

*SERUM FOR OSMOLALITY: 293 m OSM/Kg

25/5/2024:-

*APTT- 35 Sec

*PT- 18 Sec

*INR - 1.33

*CSF ANALYSIS:

Sugar- 60 mg/dl

Protein - 25 mg/dl

Chloride -119 mmol/L

*Serum electrolytes:

Sodium - 138mEq/L

Potassium - 3.3 mEq/L

Chloride - 99 mEq/L

Calcium ionized - 1.01 mmol/K

26/5/2023:-

*Blood urea- 35 mg/dl

*Serum Creatinine - 1.0 mg/dl

*Serum electrolytes:-

Sodium - 135mEq/L

Potassium- 3.2 mEq/L

Chloride- 98mEq/L

Calcium ionized - 1.09 mmol/L

*24 hours urine protein/Creatinine Ratio:-

24hrs urine protein - 2304 mg/day

24hrs urine Creatinine - 1.02 g/day

Ratio- 2.30

Urine volume- 3,200 ml

*24 hours urinary chloride:- 402 mmol/day

*24 hours urinary sodium:- 436 mmol/day

*Bacterial culture and sensitivity:-

Blood- skin commensals growth

Urine- No growth.

27/5/2023:-

Hb:-11.4 gm/dl

TLC:-17,400 cells/cumm

Neutrophils:-90 %

lymphocytes:-5%

Eosinophils:-0 

Pcv- 33.7vol%

RBC count - 3.78 millions /cumm

Platelet count- 1.75 lakhs/cumm

24/5/2023:-

CUE-

Albumin:++

Sugar. - nil

Pus cells- 1-2 

Epithelial cells -1-2

*SERUM FOR OSMOLALITY: 293 m OSM/Kg

25/5/2024:-

*APTT- 35 Sec

*PT- 18 Sec

*INR - 1.33

*CSF ANALYSIS:

Sugar- 60 mg/dl

Protein - 25 mg/dl

Chloride -119 mmol/L

*Serum electrolytes:

Sodium - 138mEq/L

Potassium - 3.3 mEq/L

Chloride - 99 mEq/L

Calcium ionized - 1.01 mmol/K

26/5/2023:-

*Blood urea- 35 mg/dl

*Serum Creatinine - 1.0 mg/dl

*Serum electrolytes:-

Sodium - 135mEq/L

Potassium- 3.2 mEq/L

Chloride- 98mEq/L

Calcium ionized - 1.09 mmol/L

*24 hours urine protein/Creatinine Ratio:-

24hrs urine protein - 2304 mg/day

24hrs urine Creatinine - 1.02 g/day

Ratio- 2.30

Urine volume- 3,200 ml

*24 hours urinary chloride:- 402 mmol/day

*24 hours urinary sodium:- 436 mmol/day

*Bacterial culture and sensitivity:-

Blood- skin commensals growth

Urine- No growth.

27/5/2023:-

Hb:-11.4 gm/dl

TLC:-17,400 cells/cumm

Neutrophils:-90 %

lymphocytes:-5%

Eosinophils:-0 

Pcv- 33.7vol%

RBC count - 3.78 millions /cumm

Platelet count- 1.75 lakhs/cumm

24/5/2023:-

CUE-

Albumin:++

Sugar. - nil

Pus cells- 1-2 

Epithelial cells -1-2

*SERUM FOR OSMOLALITY: 293 m OSM/Kg

25/5/2024:-

*APTT- 35 Sec

*PT- 18 Sec

*INR - 1.33

*CSF ANALYSIS:

Sugar- 60 mg/dl

Protein - 25 mg/dl

Chloride -119 mmol/L

*Serum electrolytes:

Sodium - 138mEq/L

Potassium - 3.3 mEq/L

Chloride - 99 mEq/L

Calcium ionized - 1.01 mmol/K

26/5/2023:-

*Blood urea- 35 mg/dl

*Serum Creatinine - 1.0 mg/dl

*Serum electrolytes:-

Sodium - 135mEq/L

Potassium- 3.2 mEq/L

Chloride- 98mEq/L

Calcium ionized - 1.09 mmol/L

*24 hours urine protein/Creatinine Ratio:-

24hrs urine protein - 2304 mg/day

24hrs urine Creatinine - 1.02 g/day

Ratio- 2.30

Urine volume- 3,200 ml

*24 hours urinary chloride:- 402 mmol/day

*24 hours urinary sodium:- 436 mmol/day

*Bacterial culture and sensitivity:-

Blood- skin commensals growth

Urine- No growth.

27/5/2023:-

Hb:-11.4 gm/dl

TLC:-17,400 cells/cumm

Neutrophils:-90 %

lymphocytes:-5%

Eosinophils:-0 

Pcv- 33.7vol%

RBC count - 3.78 millions /cumm

Platelet count- 1.75 lakhs/cumm

24/5/2023:-

CUE-

Albumin:++

Sugar. - nil

Pus cells- 1-2 

Epithelial cells -1-2

*SERUM FOR OSMOLALITY: 293 m OSM/Kg

25/5/2024:-

*APTT- 35 Sec

*PT- 18 Sec

*INR - 1.33

*CSF ANALYSIS:

Sugar- 60 mg/dl

Protein - 25 mg/dl

Chloride -119 mmol/L

*Serum electrolytes:

Sodium - 138mEq/L

Potassium - 3.3 mEq/L

Chloride - 99 mEq/L

Calcium ionized - 1.01 mmol/K

26/5/2023:-

*Blood urea- 35 mg/dl

*Serum Creatinine - 1.0 mg/dl

*Serum electrolytes:-

Sodium - 135mEq/L

Potassium- 3.2 mEq/L

Chloride- 98mEq/L

Calcium ionized - 1.09 mmol/L

*24 hours urine protein/Creatinine Ratio:-

24hrs urine protein - 2304 mg/day

24hrs urine Creatinine - 1.02 g/day

Ratio- 2.30

Urine volume- 3,200 ml

*24 hours urinary chloride:- 402 mmol/day

*24 hours urinary sodium:- 436 mmol/day

*Bacterial culture and sensitivity:-

Blood- skin commensals growth

Urine- No growth.

27/5/2023:-

Hb:-11.4 gm/dl

TLC:-17,400 cells/cumm

Neutrophils:-90 %

lymphocytes:-5%

Eosinophils:-0 

Pcv- 33.7vol%

RBC count - 3.78 millions /cumm

Platelet count- 1.75 lakhs/cumm

16/6/2023:-

Hb- 10.3 gm/dl 

TLC - 12,500

Pcv- 31.3 %

RBC -3.57

Platelet -2.36 lakhs

30/5/2023

Chest x ray after ICD tube 

grade 4 bed sore