Case 18.63 Female With sob followed by altered sensorium

Doa 23/5/24

Dod 28/5/24

Diagnosis

UREMIC ENCEPHALOPATHY

CHRONIC RENAL FAILURE SINCE 4 MONTHS

K/C/O DM2 SINCE 3 YEARS

K/C/O Htn SINCE 6 MONTHS

Case History and Clinical Findings

C/O SOB SINCE 10 DAYS

C/O REDUCED URINE OUTPUT SINCE 6DAYS

ALTERED SENSORIUM SINCE 2 HOURS

HOPI:

PT WAS APPARENTLY ASYMPTOMATIC 10DAYS AGO AND THEN DEVELOPED SUDDEN

ONSET SOB GRADE 4(NYHA) NOT ASSOCIATED WITH CHEST PAIN, PALPITATIONS,

SWEATING

C/O REDUCED URINE OUTPUT SINCE 6 DAYS

H/O PEDAL EDEMA SINCE 6 DAYS

H/O FEVER SINCE 5DAYS NOW SUBSIDED

ALTERED SENSORIUM SINCE 2 HRS

PAST HISTORY:

CHRONIC RENAL FAILURE SINCE 4 MONTHS

K/C/O DM2 SINCE 3 YEARS

K/C/O Htn SINCE 6 MONTHS

K/C/O HTN SINCE 6 MONTHS ON UNKOWN MEDICATION

NOT A K/C/O CVA, CAD, THYROID DISORDERS, ASTHMA, EPILEPSY

PERSONAL HISTORY

DIET: MIXED

APPETITE: NORMAL

BOWEL AND BLADDER MOVEMENTS: REGULAR.

NO KNOWN ALLERGIES AND ADDICTIONS.

FAMILY HISTORY: NOT SIGNIFICANT.

MENSTRUAL HISTORY: ATTAINED MENOPAUSE 15YRS AGO

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE.

NO PALLOR, ICTERUS, CYANOSIS, GENERALISED LYPHADENOPATHY,

PEDAL EDEMA PRESENT

TEMP: 96.8 F

PR: 120BPM

RR: 44CPM

BP : 140/80MMHG

SPO2: 98% @ RA

GRBS- 216

SYSTEMIC EXAMINATION:

CVS: S1 S2 HEARD. NO MURMURS

RS :TRACHEA- CENTRAL. BAE+, DIFFUSE B/L WHEEZE

P/A- SOFT, NON- TENDER. BOWEL SOUNDS

CNS:-PTVIS DROWSY BUT AROUSABLE

REFLEXES-RT LT

BICEPS ++. ++

TRICEPS ++ ++

SUPINATOR + +

KNEE ++ ++

ANKLE - -

UROLOGY REFERRAL WAS SONE ON 25/5/24 I/V/O HEMATURIA SINCE 20 DAYS.

WAS ADVICED TO SEND INVESTIGATIONS CUE,RFT,HB,URINE CYTOLOGY,USG-KUB, U/C/S.

INVESTIGATIONS WHERE SENT AND FOLLOWED UP.

ORTHO REFERRAL WAS DONE ON 27/5/24 I/V/O SWELLING OF RIGHT KNEE WITH

TENDERNESS SINCE 2 DAYS.

ADVISED RIGHT KNEE ARTHROTOMY AND LAVAGE DUE TO ? SEPTIC ARTHRITIS.

Investigation

CBP :

HB: 6.5

TC:9000 N:70 L:20 E:1 M:9 B:0 PLT: 60,000 SMEAR: NORMOCYTIC

NORMOCHROMICNameValueNameValueABG 23-05-2024 05:37:PM

PH7.00PCO214.7PO260.6HCO33.5St.HCO35.7BEB-25.9BEecf-25.6TCO28.4O2 Sat82.1O2

Count8.1RFT 23-05-2024 05:37:PM UREA273 mg/dlCREATININE16.5 mg/dlURIC ACID11.7

mmol/LCALCIUM9.0 mg/dlPHOSPHOROUS6.9 mg/dlSODIUM140 mmol/LPOTASSIUM6.1

mmol/L.CHLORIDE108 mmol/LLIVER FUNCTION TEST (LFT) 23-05-2024 06:18:PM Total

Bilurubin0.90 mg/dlDirect Bilurubin0.18 mg/dlSGOT(AST)14 IU/LSGPT(ALT)12 IU/LALKALINE

PHOSPHATASE320 IU/LTOTAL PROTEINS5.9 gm/dlALBUMIN2.5 gm/dlA/G RATIO0.76Anti HCV

Antibodies - RAPID23-05-2024 06:20:PMNon Reactive HBsAg-RAPID23-05-2024 06:20:PMNegative

ABG 23-05-2024 06:37:PM PH7.20PCO214.1PO271.0HCO35.4St.HCO38.1BEB-21.5BEecf-

21.5TCO212.4O2 Sat92.8O2 Count6.9RFT 24-05-2024 12:22:AM UREA163 mg/dlCREATININE9.7

mg/dlURIC ACID7.2 mmol/LCALCIUM9.7 mg/dlPHOSPHOROUS4.8 mg/dlSODIUM144

mmol/LPOTASSIUM4.8 mmol/L.CHLORIDE106 mmol/LCOMPLETE URINE EXAMINATION (CUE)

24-05-2024 02:21:AM COLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN++++SUGARNilBILE

SALTSNilBILE PIGMENTSNilPUS CELLS6-8EPITHELIAL CELLS2-4RED BLOOD CELLS10-

12CRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSbacteria presentRFT 24-05-

2024 11:21:PM UREA64 mg/dlCREATININE4.2 mg/dlURIC ACID2.8 mmol/LCALCIUM9.7

mg/dlPHOSPHOROUS2.7 mg/dlSODIUM139 mmol/LPOTASSIUM4.1 mmol/L.CHLORIDE106

mmol/LPOST LUNCH BLOOD SUGAR25-05-2024 12:43:AM305 mg/dlABG 25-05-2024 10:31:PM

PH7.24PCO266.9PO274.9HCO328.0St.HCO324.2BEB-0.2BEecf1.4TCO259.1O2 Sat91.8O2

Count15.2COMPLETE URINE EXAMINATION (CUE) 25-05-2024 10:49:PM COLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN++++SUGARNilBILE

SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS0-1RED BLOOD

CELLSloadedCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilABG 25-05-2024

10:51:PM PH7.37PCO236.4PO230.6HCO320.9St.HCO321.1BEB-3.3BEecf-3.4TCO244.2O2

Sat61.3O2 Count8.3RFT 25-05-2024 10:51:PM UREA97 mg/dlCREATININE5.9 mg/dlURIC ACID4.1

mmol/LCALC

IUM9.5 mg/dlPHOSPHOROUS3.3 mg/dlSODIUM148 mmol/LPOTASSIUM3.9

mmol/L.CHLORIDE106 mmol/L

SYNOVIAL FLUID CYTOLOGY(28/5/24): CYTOSMEAR STUDIED SHOWS PREDOMINANTLY

SHEETS OF NEUTROPHILIC,MACROPHAGES AND VERY FEW LYMPHOCYTES. OCCASIONAL

GIANT CELLS AND SYNOVIAL CELLS NORED, AGAINST A HAEMORRHAGIC BACKGROUND.

NO EVIDENCE OF ATYPICAL/ MALIGNANCY.

CULTURE SENSTIVITY( BLOOD ) (27/5/24): ESCHERICHIA COLI ISOLATED. RESISTANCE TO

AMOXYCLAV,CEFTRIAXONE.

CULTURE SENSTIVITY( URINE ) (27/5/24): ESCHERICHIA COLI >10X5 CFU/ML OF URINE

ISOLATED. RESISTANCE TO

AMOXYCLAV,CEFTRIAXONE,COTRIMOXAZOLE,NORFLOXACIN,OFLOXCIN.

2D ECHO(28/5/24): EF-46% IVC SIZE: 2.26CMS COLLAPSING.

MODERATE TR WITH PAH.

MODERATE AR,MR.

GRADE 1 DIASTOLIC DYSFUNTION.

MODERATE LV SYSTOLIC FUNTION.

ECG: SINUS TACHYCARDIA OBSERVED.

Treatment Given(Enter only Generic Name)

1) INJ.MONOCEF 1GM IV/BD

2) INJ.LASIX 40MG IV/TID

3) INJ.LEVIPIL 500MG IV/BD

4) INJ.OPTINEURIN 1AMP IN 500ML NS IV/OD

5) INJ.IPO 4000IU SC/WEEKLY ONCE

6) INJ.HAI SC/TID

7) TAB.NODOSIS 500MG PO/BD

8)TAB.PCM 650MG PO/TID

9) CAP.BIO D3 PO/ TWICE WEEKLY

FOLLOW Up

pateint expired in outside hospital