70 yr old male patient with Altered Sensorium.
B.Shradha.
Rollno-10.
8th semester.
Under the Guidance of Dr.VamsiKrishna(PG-1)
This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
I have 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 a diagnosis and treatment plan.
CASE:-
A 70 yr old Male came to the casuality in unresponsive State Since 02-06-2021 Afternoon.
CHEIF COMPLAINTS & HOPI :-
* Patient was apparently asymptomatic 2 yrs back.
* Then he developed pedal edema ,which was sudden in onset , progressive not associated with SOB ,Facial Puffiness, decreased urine output.
* He went to local hospital,on routine blood investigations- pt's attenders said orally - that he had raised RFT on medical management for 15 days &then discontinued.
* He was asymptomatic till 1 week ,had sudden onset of pedal edema.,which is progressive upto b/l knee associated with SOB @Rest Since yesterday.
* Altered Sensorium associated with GCS -E1V1M4,Since afternoon.
* Anuria since morning.
HISTORY OF PAST ILLNESS:-
* No history of HTN/DM -II/TB/Epilepsy/CVA/CAD.
FAMILY HISTORY:-
* Not Significant.
PERSONAL HISTORY:-
* DIET -mixed.
* APEPTITE- decreased.(since 1 week).
* BOWEL AND BLADDER MOVEMENTS- Irregular and abnormal.
* ADDICTIONS -tobacco and alcohol for 40yrs , stopped 20yrs back.
GENERAL EXAMINATION:-
* Patient is moderately built , unconscious,non coherent ,not well oriented to time ,place and person.
* NO-pallor ,Icterus , Clubbing,cynaosis,lymadenopathy and oedema.
* Temp : Afebrile
* Pulse rate: 135bpm.
* Resp rate : 38cpm.
* Bp : 120/80mmof Hg.
* SpO2: 63% at room air.
* GRBS: 51 mg /dl.
* REFLEXES:-
Biceps. Triceps supinator
Right. 2+. +. +
Left 2+. +. +
#Knee and ankle reflexes are negative on both side.
*CEREBRAL SIGNS :-
Finger- Nose in -coordination &
Knee -Head in - Coordination- cannot be elicted.
*SYSTEMIC EXAMINATION:-
# Cardio vascular system-
-No thrills
-S1,S2 (+)
-No cardiac murmurs.
# Respiratory system-
- Dyspnea -present.
-wheeze. - present.
- breath sounds - vesicular.
-position of trachea - central.
- Cryptus- positive in all areas .
# Abdomen-
- scaphoid shaped.
- No tenderness,palpable mass, free fluid
- bowel sounds - heard.
- Liver and spleen - not palpable.
# Central nervous system-
- Levels of consciousness- E1V1M4.
- speech - No response.
- Signs of meningeal Irritation-
Neck stiffness and kerning sign- Absent.
- cranial nerves.Motor system , Sensory system- cannot be elicted.
-Glasgow Scale-E1V1M4.
* PROVISIONAL DIAGNOSIS:-
-Altered Sensorium Under Evalution. Secondary to Hypoxia/Hypoglycemia.
-CKD - Stage 5.
-Refractory hypotension
- Refractory Metabolic Acidosis.
*INVESTIGATIONS:-
#ABG VALUES:-
PRE INTUBATION POST INTUBATION
PH. -. 6.93. 7.0. 7.07. 7
PCO2- 37.3. 77.3. 53.3. 77.3
PO2- 71.6. 92.2. 75.1. 92.2
HCO3- 7.5. 13.8. 15.1. 18.4
SpO2- 75.7. 89.5. 87.3. 89.5
#HEMOGRAM:-
Hb : 10.4gm/dl.
TC: 6800 cells /mm3.
N/L/E/M/B : 94/4/1/1/0.
PCV :. 30.1 L/L.
Platelet count : 1.3 cells/mm3
*Albumin -2+
* Pus cells: 8-10
#RFT :-
Creatinine -6.8 mg/dl
Urea - 131mg/dl
Uric acid - 6.7 mg/dl
Ca+2 - 9.3 mg/dl
Phosphorous- 5.2 mg/dl
Na+2 : 145.mmol/L
K+. : 3.8mmol/L
Cl- : 106mmol/L
#LFT :-
Tot bilirubin - 1.58mg/dl
Direct bilirubin - 0.75mg/dl
AST - 68 IU/L
ALT -29 IU /L
Alk phos- 305 IU/L
TP - 4.2 gm/dl
Albumin - 2.4 gm/dl
#ECG:-
On Day 1 (02/06/2021)- On admitted day.
On Day 2 (03/06/2021)- At 10:30AM.
* TREATMENT:-
(1) IVF -0.9%NS.
(2)Optineuron- 75ml/hr.
(3)INJ .PAN -40 mg /Iv/ OD.
(4)INJ .MIDAZOLAM -2cc/ IV / SOS.
(5)GRBS charting - 4 hrly.
(6).Head end elevation.
(7).monitor- Bp,PR,RR.
(8) Strict I/O Charting.
*DEATH SUMMARY:-
#70 yr old male came to casuality in unresponsive State.Since 4hrs (i.e 12pm on 02/06/2021) associated Sudden loss of speech ,not even walking,not responding to commands associated with Anuria in the mrng & pedal edema since 4-5 days ..
#on presentation pt has hypotension & hypoxia with type 1 respiratory faliure ,so immediate intubation was done & put on mechanical ventilation.
#On presentation he has severe metabolic acidosis, Anuria, refractory hypotension since 12:00pm night and started on Ionotrophs &IvF bolus.
#At 10:30Am ,pt has sudden onset of LBBB(2o MI).&Sudden cardiac arrest ,pulse ,BP, not recordable- CpR Intiated at 11:40pm .
# Despite the treatment & Resuscitation Patient could not be revived & declared death on 03/06/2021at 12:10pm.
IMMEDIATE CAUSE OF DEATH:
New onset LBBB (secondary to MI).
Refractory Hypotension.(secondary to Sepsis &. Pneumonia).
Refractory Acidosis.
With left lobe consolidation.
ANTECEDENT CAUSE :-
CRF -Stage 5
With Altered Sensorium secondary to hypoxia/uremic.
HYPOGLYCEMIA (Metabolic Infective)
Thank you Dr.vamsi krishna (PG-1)for the guidance.
Thank you Dr.Rakesh Biswas sir for the opportunity.
