1701006106 CASE PRESENTATION

LONG  CASE  

50 year old male patient with weakness of the  lower limbs bilaterally since 2 days. 

He is a resident of Nalgonda, and a daily wage worker till one year ago. He had a fainting episode after which he stopped going to work. 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 4 months back , when he developed pain in the right hip region, which was insidious in onset and intermittent at the beginning.

Pain aggravated on movement and relieved on rest and medication. 

He went to the hospital 2 months ago when the pain progressed and became continuous and was diagnosed with avascular necrosis of the femur due to a trauma to the hip one year ago. 

2 days ago, patient developed weakness in the lower limb which progressed upto the hip.

The next morning, patient required assistance to walk and sit up but was able to feed himself.

The weakness progressed and by evening he was unable to feed himself. He only responded if called to repeatedly. 

The weakness was not associated with loss of consciousness, slurring of speech, drooping of mouth, seizures, tongue bite or frothing of mouth, difficulty in swallowing.

No complaints of any headache, vomitings, chest pain, palpitations and syncopal attacks. 

No shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, abdominal pain or burning micturition. 

HISTORY OF PAST ILLNESS:

No similar episodes in the past. 

Patient is a known case of diabetes since 12 years. He is on regular medication, with 15 U INSULIN in the morning before breakfast and 10 U in the evening (7-7:30pm). 

He was hospitalized, 4 years ago with low blood sugar, and was admitted for 10 days. He presented with altered mental status. 

No history of hypertension, tuberculosis, epilepsy, asthma, thyroid and CAD. 

No surgical history. 

PERSONAL HISTORY:

Diet: Mixed 

Appetite: Normal

Sleep: Adequate 

Bowel and Bladder: Regular bladder, decreased bowel movements.

No allergies

Started alcohol intake 25 years back, stopped 12 years when diagnosed with diabetes. He used to binge drink alcohol for 10 days continuously every month and then used to stop for 20 days. Cycle repeats every month. Now, consuming alcohol only on special occasions, doesn't exceed 90ml. 

Started smoking beedis, one a day, 10 years ago. 

Stopped 4 years ago when he went into a hypoglycemic episode, but has resumed one year ago. 

FAMILY HISTORY: 

No similar complaints in family. 

GENERAL EXAMINATION:

Patient is examined in a well lit room after taking informed consent. 

Patient is conscious, coherent and cooperative. 

He is moderately built and moderately nourished. 

Pallor: Present 

Icterus: absent

Cyanosis: absent

Clubbing: absent 

Generalized Lymphadenopathy: absent

Edema: Absent

VITALS:

Temperature: Afebrile

Blood Pressure: 124/72 mmHg

Respiratory Rate: 17 cycles per minute

Pulse: 70 bpm

SYSTEMIC EXAMINATION: 

CENTRAL NERVOUS SYSTEM EXAMINATION.

Higher mental functions

          • conscious

          • oriented to person and place

          • memory - able to recognize their family members and recall recent events

          • Speech - no deficit

Cranial nerve examination 

          • 1 - couldn't be elicited

          • 2- Direct and indirect light reflex present

          • 3,4,6 - no ptosis Or nystagmus

          • 5- corneal reflex present 

           • 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present

          • 8- able to hear

          • 9,10- position of uvula is central

          • 11- sternocleidomastoid contraction present

          • 12- no tongue deviation

 Motor system 

Attitude - right lower limb flexed at knee joint

                            Right                  Left

BULK 

Arm.                   22 cm.                22cm

Forearm.          20.5cm             20.5cm

Thigh.                 34cm.                 34cm

Leg.                    26cm.                 26cm                         

TONE

 Upper limbs.       N.                        N

 Lower limbs.       N                         N

POWER

 Upper limb      

  Elbow- Flexor.    5/5.                     5/5

              Extensor  5/5                      5/5

 Wrist- Flexor.      5/5.                     5/5

            Extensor   5/5.                     5/5

Hand grip.            5/5.                      5/5

 Lower limb

 Hip- Flexors.       5/5.                    5/5

         Extensors.   5/5.                    5/5

Knee- Flexors.     5/5.                    5/5

          Extensors.  5/5.                    5/5 

Ankle- DF.           5/5.                    5/5

            PF.           5/5.                     5/5

EHL.                   5/5.                     5/5

FHL.                   5/5.                     5/5

REFLEXES.       Right.                Left

Biceps.                 2+                     2+

Triceps.                2+                     2+

Supinator.            2+                     2+

Knee.                   2+                     2+

Ankle.                  2+                     2+

Gait is normal

No involuntary movements

Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are normal.

CARDIOVASCULAR SYSTEM

INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses

Apical impulse and pulsations cannot be appreciated

PALPATION:

Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.

No parasternal heave, thrills felt.

PERCUSSION:

Right and left heart borders percussed.

AUSCULTATION:

S1 and S2 heard , no added thrills and murmurs heard.

RESPIRATORY SYSTEM

INSPECTION:

Chest is bilaterally symmetrical

Trachea – midline in position.

Apical Impulse is not appreciated 

 Chest is moving normally with respiration.

No dilated veins, scars, sinuses.

PALPATION:

Trachea – midline in position.

Apical impulse is felt on the left 5th intercoastal space.

Chest is moving equally on respiration on both sides?

PERCUSSION:

The following areas were percussed on either sides- 

Supraclavicular

Infraclavicular

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Upper/mid/lower interscapular were all RESONANT.

AUSCULTATION:

Normal vesicular breath sounds heard 

No adventitious sounds heard.

ABDOMEN EXAMINATION

INSPECTION:

Shape – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving equally with respiration.

No dilated veins, hernial orifices, sinuses

No visible pulsations.

PALPATION:

No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- no organomegaly.

PERCUSSION:

There is no fluid thrill , shifting dullness.

Percussion over abdomen- tympanic note heard.

AUSCULTATION:

 Bowel sounds are heard.

PROVISIONAL DIAGNOSIS:

BILATERAL LOWER LIMB WEAKNESS DUE TO AN ENDOCRINAL OR METABOLIC CAUSE IN A PATIENT WITH DIABETES MELLITUS WITH A HISTORY OF AVASCULAR NECROSIS OF HEAD OF FEMUR.

INVESTIGATIONS:

HEMOGRAM:

Hemoglobin: 8.6

TLC: 18380

N/L/E/M: 86/06/1/5

Platelet: 2.02

MCV: 71.6

MCH: 24.2

RDW: 15

PCV: 26.4

RBC COUNT: 3.63

ELECTROLYTES:

Na: 145

Cl: 110

K: 2.5

RENAL FUNCTION TESTS

Urea: 74

Creatinine: 3.7

Urine protein / creatinine: 0.27

Spot urine protein: 14.2 mg/ dl

Spot urine creatinine: 51.1mg/dl

LIVER FUNCTION TESTS

Total Bilirubin: 1.34

Direct Bilirubin: 0.55

SGOT:24

ALT:12

ALP:259

Total Protein: 6.3

Albumin: 2

A/G: 0.73

On 3/6

On 4/6

On 5/6

GRBS

On day 1

4:30 pm - 272gm/dl

On day 2

8am - 178/dl ( 4U HAI)

12pm- 205mg/dl

8pm -  176 mg/dl ( 8U HAI)

On day 3

12am - 120mg/dl

8am - 180mg/dl

2pm - 223mg/dl ( HAI 12 U)

On day 4

12 am - 210mg/dl

8 am - 302mg/dl

8pm- 203mg/dl

On day 5

2 am - 75mg/dl

8 am - 160mg/dl

8pm 478mg/dl

10pm- 325 mg/dl

ECG :

On 2/6

On 3/6

On 4/6

On 5/6

PROVISIONAL DIAGNOSIS:

TREATMENT:

on day 1

1) tab ecospirin 70mg OD

2) tab atorvas 10mg OD

3) inj NS, RL at 70ml/hr

4) syrup potchlor  15ml/po/tid

5) normal oral diet

6) inj HAI - TID

7) 2 amp KCL in 500ml NS slowly over 4-5 hrs

On day 2

1) tab ecospirin 70mg OD

2) tab atorvas 10mg OD

3) inj NS, RL at 70ml/hr

4) syrup potchlor 15ml/po/tid

5) normal oral diet

6) inj HAI - TID

7) proteolytic enema

8) syrup cremaffine

9) tab spironolactone

On day 3

1) tab ecospirin 70mg OD

2) tab atorvas 10mg OD

3) inj NS, RL at 70ml/hr

4) syrup potchlor 15ml/po/tid

5) normal oral diet

6) inj HAI - TID

7) proteolytic enema

8) syrup cremaffine plus 15ml/po/od

9) tab spironolactone 25mg/po/od

10) tab azithromycin 500mg OD

11) high protein diet 

On day 4

1) tab ecospirin 70mg OD

2) tab atorvas 10mg OD

3) inj NS, RL at 70ml/hr

4) syrup potchlor 15ml/po/tid

5) normal oral diet

6) inj HAI - TID

7) tab ultracet QID

8) syrup cremaffine plus 15ml/po/od

9) tab spironolactone 25mg/po/od

10) tab azithromycin 500mg OD

11) high protein diet 

On day 5

1) tab ecospirin 70mg OD

2) tab atorvas 10mg OD

3) inj NS, RL at 70ml/hr

4) syrup potchlor 15ml/po/tid

5) normal oral diet

6) inj HAI - TID

7) tab ultracet 1/2 po/ QID

8) syrup cremaffine plus 15ml/po/od

9) tab spironolactone 25mg/po/od

10) tab azithromycin 500mg OD

11) high protein diet 

--------------------------------------------------------------------------

SHORT CASE 

A 46 year old male came to casuality with chief complaints of 

-burning micturition since 10days 

-hiccups since 3days

-vomiting since 2days (3-4 episodes)

-giddiness and deviation of mouth since 1day.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 10days back, when he developed burning micturition , not associated with fever and decreased urine output. 
3 days back then pateint complaints of hiccups.

2 days back, patient developed vomitings , 4-5 episodes, containing food particles, non bilious.

Patient complaints of deviation of mouth and giddiness one day, he was brought to the hospital and his GRBS was recorded to be high for which he was given NPH 10 IU and HAI 10 IU.

No c/o fever/cough/cold/ abdominal pain.
No c/o chest pains/palpitations/syncopal attacks.

HISTORY OF PAST ILLNESS:

10years back patient complained of polyuria after which he was diagnosed with Type 2 Diabetes Mellitus, he was started on oral hypoglycemic agents(OHA), which he took on and off due to financial crisis.

3years back OHAs were replaced by Insulin, he is taking insulin three times a day before food regularly.

3years ago he underwent a cataract surgery in the right eye.

1year ago he had injury to his right leg, which gradually progressed to non healing ulcer extending upto below knee and ended with undergoing below knee amputation due to developement of wet gangrene.

Delayed wound healing was present- it took 2months to heal

Not a k/c/o Hypertension, Epilepsy,Tuberculosis, Thyroid

Not on any medication

No history of blood transfusion 

PERSONAL HISTORY:

Diet : Mixed
Appetite : normal
Sleep : Adequate 
Bowel and bladder : Regular bowel
Micturition : burning micturition present
Habits/Addiction:
Alcohol- 
Not consuming alcohol since 1 yr.

Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.

FAMILY HISTORY: 

Not significant 

GENERAL EXAMINATION:

Patient is examined in a well lit room after taking informed consent. 

He is moderately built and moderately nourished. 

Pallor: Present 

Icterus: absent

Cyanosis: absent

Clubbing: absent 

Generalized Lymphadenopathy: absent

Edema: Absent

VITALS:

Temperature: 101F

Blood Pressure: 110/80mmHg

Respiratory Rate: 18 cycles per minute

Pulse: 98 bpm

SPO2: 98% on RA

GRBS: 124mg/dl

SYSTEMIC EXAMINATION: 

ABDOMEN EXAMINATION

INSPECTION:

Shape – scaphoid

Flanks – free

Umbilicus –central ,  inverted.

All quadrants of abdomen are moving with respiration.

No dilated engorged veins

No visible pulsations, visible peristalsis and scars.

PALPATION:

No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- 

Liver : palpable just below costal margin ( right)

Sleep : not palpable 

Kidney : not palpable

PERCUSSION:

There is no free fluid

Percussion over abdomen- tympanic note heard.

AUSCULTATION:

Bowel sounds heard.

CVS: S1S2 heard, No murmurs

RS: BAE+,NVBS

CNS:  
Higher function test: 
Patient is having altered sensorium 
Slurred speech 
Not Orientated to time place person.
Memory couldn't be elicited as patient is in altered sensorium 

Cranial nerves : intact 

Motor system :   

1. Bulk :                right.                    Left 
Upperlimb          normal.                Normal
Lowerlimb.        thigh -N.                Normal 
                          Below knee amputated on R side
2. Tone : 
Upperlimb.          Normal.             Normal 
Lowerlimb.         Normal.             Normal 

 3. Power :
Neck: Normal 
Trunk: Normal
         Upper limb       5                        5
         Lower limb       5                        5 

 4. Reflexes 
                                     Right           Left 
                Biceps            2+.                  2+
                Triceps           2+                   2+
               Supinator         2+                  2+
                Knee               -                     2+
               Ankle               -                     2+
         Planter reflex     Amputated     flexion

Sensory system : normal 

Meningeal signs  : negative

PROVISIONAL DIAGNOSIS:

Right (emphysematous?) pyelonephiritis and left acute pyelonephiritis and encephalopathy secondary to sepsis.

H/o of Type 2 Diabetes mellitus since 10years.

INVESTIGATIONS:

ON DAY OF ADMISSION:

HEMOGRAM:

Hemoglobin: 8.0 g/dl

TLC: 22900 cells/cumm

N/L/E/M: 89/03/1/7

Platelet: 1.50

MCV: 73.5

MCH: 27.2

RDW: 11.7%

PCV: 21.6

RBC COUNT: 2.94

# NEUTROPHILIC LEUKOCYTOSIS.

ELECTROLYTES:

Na: 124

Cl: 80

K: 2.6

RENAL FUNCTION TESTS

Urea: 129

Creatinine: 4.7

Urine for ketone bodies- negative 

LIVER FUNCTION TESTS

Total Bilirubin: 1.52

Direct Bilirubin: 0.50

SGOT:21

ALT:10

ALP:275

Total Protein: 5.6

Albumin: 2.3

A/G: 0.72

X-ray KUB

CT SCAN

ON DAY 2:

LDH- 192

24hr Urinary protein- 434

24hrs Urinary creatinine- 0.5

 

ON DAY 3

Hemoglobin- 6.8g%

TLC- 22,500cells/cumm

Platelets- 1.4lakhs/cu.mm

Urea- 155mg/dl

Creatinine- 4.7

Uric acid- 7.1

Phosphorus- 2.0

Sodium- 126

Potassium- 2.6

Chloride- 87

ON DAY 4

Hemoglobin- 7.2

TLC- 17,409

Platelet count- 1.5

Urea- 162

Uric acid- 5.0

Sodium- 125

Chloride- 88

ON DAY 5

ON DAY 6

ON DAY 7

Hb- 7

TLC- 22,000

Platelet count- 26,000

Urea- 144

Creatinine - 4.8

Uric acid-9.1

Phosphorus- 4.8

Sodium- 135

Potassium- 4.3

Chloride- 98

Fasting blood sugar- 149

ON DAY 8

Hb- 6.4

TLC- 14,700

Platelet count- 6000

Urea - 149

Creatinine- 4.4

Uric acid- 9.2

TEMPERATURE CHARTING- 

INTERPRETATION- 

After one week of use of meropenam the fever spikes have shown a fall and there is no new complaint by patient. The WBC counts have also reduced and patient's condition have been improving

TREATMENT:

Day 1 to Day 3:

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. PAN 40mg IV OD

IV Fluids- NS,RL @ 100 mL/hr

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

Day 4

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. KCl 2 Amp in 500 mL NS over 4.5 hrs infusion

IV Fluids- NS,RL @ 100 mL/hr

SYP. POTCHLOR 10 mL in 1 glass of water TID

SYP. MUCAINE GEL 10 mL PO TID

7 point profile

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

Day 5 to Day 10:

INJ. MEROPENEM 500mg IV BD (Day 6)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

Day 11:

INJ. COLISTIN 2.25 MU IV OD(Day 4)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

Day 12:

SDP Transfusion done I/v/o low platelet count 

Pre transfusion counts:

Hb:6.2 g/dL

TLC:14700

PLt:6000

Post transfusion counts:

Hb:6.4

TLC:13700

PLt:50000

INJ. COLISTIN 2.25 MU IV OD(Day 5)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS