A 39year old male elog.

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Patient was admitted to the hospital on 9th November, 2021.

 

Chief complaints(as told by the patient's attender because he was unconscious at the time). 

Since 10 days low grade fever and nausea and chills intermittently.

No h/o headache, blurring of vision or vomitings.

 -Loss of appetite since 2 days .

Since one day ,pt was unable to speak. but understanding commands .

Past Medical history :

All his medical history started 8 months ago .

**8 months ago -- c/o low back ache , pain abdomen -- was told to have renal stones , meatal stenosis--underwent urethral dilatation in July 2021.

He visited a hosp in Nalgonda ,where he was incidentally detected with creat of 5 mg/dl.

His urine output was good and he had no pedal edema or sob. He was told to have renal failure and was on medication since then.

He even had h/o wt loss and loss of appetite and low grade fever. 

He was having intermittent back pain since then .

After 2 months in August ,

** August last week , 2021 -- c/o left lower limb weakness, slow gradually progressed to right LL -- B/L Paraplegia. 

Used ATT for 15 days and stopped , due to nausea and loss of appetite, patient was bedridden since, then and used unani medication.

Pt was neglected and using Unani medications inspite of advising to use ATT.

**H.D was adviced 2 months ago - but didn't get it done due to fear of death ( among relatives deaths on H.D+)

** Since September 2021--Bed sores developed,  1 daily dressing done ,but patient was active and talks to everyone.

**C/o low grade fever since 10 days  ,nausea , shivering+. No h/o loose stools , vomitings , headache, blurred vision.

** Since 1 day-- loss of appetite, unable to speak( sudden in onset) -- but obeying commands .

Since today-- Altered sensorium , no response to commands . Involuntary movements of b/l lower limbs(Rt>lft)

**8 months back went to a physician for low back ache and diagnosed with RENAL CALCULI WITH INCREASED SR.CREATINIE.

**flaccid paraplegia  since 2 months bed ridden ..used ATT for 15 days and stopped.

Personal history:

N/o h/o DM , HTN, EPILEPSY, ASTHMA.

He has normal appetite , consumes mixed diet with regular bowel movements, he was on Foley's since 6 months .

No addictions.

General examination:-

Pallor+

No icterus, cyanosis, clubbing edema , lymphadenopathy.

VITALS ON ADMISSION:- 

Temp:- 101F 

PR:- 92 BPM

RR:-14 cpm

BP: 90/60 mmHG

Spo2:- 83 % at RA

GRBS:- 195 MG%

CVS examination:-

 S1 S2+ ,NO MURMUR

RS examination:- 

Bilateral airway entry+ , NVBS+

P/A SOFT ,Non tender. 

CNS examination:-

 Eye opening to pain

 No verbal  response

No meningeal signs

GCS:- E2 V1 M5. 8/15

PUPILS--B/L mid dilated unequal(Rt>Lft)

Plantars-- B/l Flexion 

Tone --

 Upper limb- Increased.Increased

 Lower limb- Decreased.decreased.

Power- --.      RT.       LT

 Upper limb - 5/5.    5/5

 Lower limb- plegia plegia(0/5)

Reflexes:-  RT.             LFT

            Biceps-    absent.      2+

            Triceps-.     3+.             3+

            Supinator-.      2+.           2+

            Knee jerk-.      Absent.   Absent

            Ankle jerk-.       Absent.    Absent.

Provisional diagnosis:- 

1) ALTERED SENSORIUM UNDER EVALUATION 

SECONDARY TO? POST ICTAL CONFUSION WITH ? ACUTE ISCHEMIC CVA( PARIETO TEMPORAL AREA) . or ? uremic encephalalopathy.

3) ? TB - VASCULITIS/ SEPTIC INFARCT

4) PARAPLEGIA SECONDARY TO POTTS SPINE 

5) CKD

6) ANEMIA UNDER EVALUATION

7) GRADE 3 BED SORE.

 Laboratory Investigations:-

HB:- 3.8

PLT :- 61000

BGT:- A Positive

Na-137

K-4.3

Cl-98

Sr.creat-4.2

LFT:-

TB- 0.92

DB-0.27

SGOT-18

SGPT-24

ALP-375

TP- 4.7

ALBUMIN:-2.0

A/G :-0.76

LDH:- 225

Blood urea- 247

Rbs-143

Serology--NEGATIVE

C-reactive protein-- POSITIVE-2.4 mg/dl.

TREATMENT :-

1) IVF NS-2 units 

           RL-1 unit 

           Dns- 1 unit @ 100 ml/hr

2) Inj. Optineuron 1 amp in 100 ml NS  IV OD 

3) Inj. Levipil 1 gm IV stat--500 mg iv bd

4) RT Feeds milk + Protein powder 4th hourly..free water 200 ml 4th hourly

D1-5) Inj. Ceftriaxone 2gm iv bd

6) Inj. Neomol 1 gm IV SOS

7) Tab. Dolo 650 mg RT TID

8) Inj. Pantop 40 mg IV OD

9) ATT According to renal clearance and wt.

10) GRBS 12 TH HOURLY 

I/O CHARTING

BO/PR MONITORING.

11) INJ. Pan 40 mg /Iv /Od

12) Inj. ZOFER 4 mg iv bd