70 year old man with c/o irrelevant talks since 3 days , reduced urine output since 3 days
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THIS IS THE CASE I HAVE SEEN -
Unit 3:
Interns:
Dr. Kalyan
Dr. Sreeja
Dr. Archana
Dr.Harsha
Dr. Jeeharika
Dr. Raveen
Dr. Aashita
Dr. Vamshi
Dr. Aravind
Dr. Manasa ICU PG
A 70 year old presented to the casaulty with the complaints of
Irrevalent talks since 3 days
Reduced urine output since 3 days
Fever and cough since 2 days
Dyspnea at rest since morning
3 episodes of stools since morning
He works as a coolie at a local village along with his wife. He has 6 children - 3 sons, 3 daughters. He has been an occasional tody drinker since 40 years.
He used to smoke tobacco everyday 30 years back.
He had bilateral eye surgery 1 year back.
Since the past 3 days he has been having irrevalent talks. He also has been having fever on and off, associated with chills since 2 days along with cough.
Since morning he has had 3 episodes of semi solid stools.
On examination:
The patient is a thin built man
with no pallor, icterus, cyanosis, clubbing
His heart rate is 105bpm with a blood pressure of 120/70mmhg
His respiratory rate is 28cpm with sats of 94%
Temp 100 F
Grbs is 105mg/dl
Gcs - E 4 V 3 M 5
Pupils reacting to light bilaterally
His lungs have bilateral inspiratory crepitations on auscultation in IAA, ISA
CVS - S1,S2
Per abdomen - Diffuse Tenderness
HisbECG shows sinus rhythm, with tall T waves in v3,v4.
pH - 7.32
pco2 - 22.4
Hco3 - 11.3
His Blood Urea - 177
Sr creatinine - 5.5
Na - 135
K - 4.7
Cl - 102
Hb - 8.7
TLC - 4000
Plt - 1 Lakhs/cumm
Dx-
? Meningitis
? Uremic Encephalopathy
AKI with Bilateral Hydronephrosis
DAY 1 : 17/2/21
PROVISIONAL DIAGNOSIS - 1. UREMIC ENCEPHALOPATHY 2.AKI 3. B/L HYDRONEPHROSIS
PR-86 BPM ; BP - 120/70 MM HG ;RR - 16CPM ,SPO2 - 97% ; TEMP - 98.4 F ; CVS- S1,S2 + ; R/S - BAE+
DIAGNOSIS -
1. HEAD END ELEVATION
2.O2 SUPPLEMENTATION IF SP02 < 90%
3. IVF 2 NS , 1 RL, 1 DNS @URINE OUTPUT + 30ML/HR
4.INJ PANTOPRAZOLE 40 MG / IV OD
5.TAB DOLO 650 MG / PO/ SOS
6. INJ NEOMOL 100 ML / IV IF TEMP >= 101 F
NEBULIZATION WITH MUCOMIST 6TH HOURLY
7. TEMPERATURE MONITORING , TEPID SPONGING
8. NEBULISATION WITH MUCOMIST 6TH HOURLY
9. MONITOR VITALS , INPUT OUTPUT CHARTING.
10. INJ MONOCEF 1 GM /IV/BD
ECG -
17/2/21 CHEST XRAY -
2D echo -
17/2/2021 HEMOGRAM-
17/2/2021 CUE-
17/2/2021 LFT-
17/2/2021RFT-
17/2/2021 TROPONIN I
DAY 2: 18/02/2021
18-2-2021
PATIENT SENSORIUM IMPROVED BUT HE WAS STILL CONFUSED AND THERE WAS IRRELEVANT TALKS PRESENT.
PROVISIONAL DIAGNOSIS - 1. UREMIC ENCEPHALOPATHY 2.AKI 3. B/L HYDRONEPHROSIS
PR-82 BPM ; BP - 110/70 MM HG ;RR - 16CPM ,SPO2 - 97% ; TEMP - 98.4 F ; CVS- S1,S2 + ; R/S - BAE+
Rx -
1. HEAD END ELEVATION
2.O2 SUPPLEMENTATION IF SP02 < 90%
3. TEMP CHARTING 4TH HOURLY , TEPID SPONGING .
4. MONITOR VITALS
5.STRICT I/O CHARTING
6. NEBULIZATION WITH MUCOMIST 6TH HOURLY
7. IVF NS/RL/DNS @ 1OO ML /HR
D1 - 8. INJ MONOCEF 1 GM /IV/BD
9.INJ PANTOPRAZOLE 40 MG / IV OD
10. TAB DOLO 650 MG / PO/ SOS
11. INJ NEOMOL 100 ML / IV IF TEMP >= 101 F
19-2-2021
kernigs + , neck stiffness + C/O IRRELEVANT TALK + , FEVER SINCE LAST NIGHT
PROVISIONAL DIAGNOSIS - ? 1.MENINGITIS 2. UREMIC ENCEPHALOPATHY 3.AKI SECONDARY TO B/L HYDRONEPHROSIS
PR-92 BPM ; BP - 140/90 MM HG ;RR - 16CPM ,SPO2 - 97% ; TEMP - 100 F ; CVS- S1,S2 + ; R/S - BAE+
DIAGNOSIS -
1. HEAD END ELEVATION
2.O2 SUPPLEMENTATION IF SP02 < 90%
3. TEMP CHARTING 4TH HOURLY , TEPID SPONGING .
4. MONITOR VITALS
5.STRICT I/O CHARTING
6. NEBULIZATION WITH MUCOMIST 6TH HOURLY
7. IVF NS/RL/DNS @ 1OO ML /HR
D2 - 8. INJ MONOCEF 1 GM /IV/BD
9.INJ PANTOPRAZOLE 40 MG / IV OD
10. TAB DOLO 650 MG / PO/ SOS
11. INJ NEOMOL 100 ML / IV IF TEMP >= 101 F
AT 8:30 PM LUMBAR PUNCTURE WAS DONE AND WAS UNEVENTFUL .
AT 10 PM PATIENT WAS STILL IN ALTERED SENSORIUM AND DUE TO RISING UREA AND CREATININE LEVELS PATIENT WAS TAKEN FOR DIALYSIS AND CENTRAL LINE WAS PUT . CENTRAL LINE WAS UNEVENTFUL .
CENTRAL LINE WAS PLACED IN IJV AND PATIENT WAS TAKEN FOR HEMODIALYSIS.
AT START OF HEMO DIALYSIS , PT WAS IN ALTERED SENSORIUM AND HAD COOL EXTREMITIES .
BP- 110/90 MM HG
PR- 112 BPM
SPO2 - 88% ON 10 L OF OXYGEN ----> PATIENT WAS STARTED ON inj. NOR-ADRENALINE. @ 4ML/HR
AFTER HALF HOUR OF HEMODIALYSIS , IN VIEW OF FALLING SATURATIONS , PATIENT WAS INTUBATED WITH 7.5 MM ET TUBE , AFTER NECESSARY PRE-MEDICATION .
POST - INTUBATION , CENTRAL PULSE PRESENT, PERIPHERAL PULSES FEEBLE , EXTREMITIES COOL , PUPILS B/L MID DILATED NOT REACTIVE TO LIGHT .
BP - NOT RECORDABLE---> NA RAISED TO 10 ML /HR.
PR-110 BPM
CVS- S1S2 +
RS - BAE + ; DECREASED AIR ENTRY ON LEFT SIDE . HD WAS STOPPED AND PATIENT WAS SHIFTED BACK TO ICU .
PRE INTUBATION ABG - PH - 6.97
PCO2- 43 MM HG
PO2 -
SPO2 -
HCO3 - 8 ML/LIT
POST INTUBATION ABG - PH 7.066
PC02 - 13
SPO2- 97%
HCO3 - 3.7 . INJ SODIUM BICARBONATE 50 MG/IV/STAT WAS GIVEN , NA WAS RAISED TO 15ML/HR .
PATIENT CONNECTED TO MV ON IPPV MODE .
RR- 14 CPM , FI02 - TAPERED FROM 100 TO 60 %
PEEP- 5 MM HG
VT- 360 ML
PROVISIONAL DIAGNOSIS - AKI SECONDARY TO B/L HYDROURETERONEPHROSIS/ ? SEPSIS
GROSS PLEURAL EFFUSION
TYPE 1 RESPIRATORY FAILURE.
? VIRAL MENINGITIS
SEVERE METABOLIC ACIDOSIS .
INJ NORADRENALINE 15 ML / HR INFUSION ( INCREASED OR DECREASED TO MAINTAIN MAP >68 MM HG.
INJ DOBUTAMINE @ 3 ML /HR INFUSION .
INJ NAHCO3 100 MEQ IN 100 ML NS / IV SLOWLY OVER 30 MIN
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