medicine e blog by NIKITHA

CBBLE UDHC SIMILAR CASES

CASE OF  A-HHS WITH DIABETIC NEPHROPATHY

 


THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 


  Feb 6,2022
A 50 year male farmer ,manual labourer,brought  to casualty with h/o altered sensorium since 1 day
H/o fever since 4 days.
HISTORY OF PRESENTING ILLNESS -
Patient was apparently asymptomatic 4 days ago,then he developed fever which is high grade,No diurnal variation, associated with chills.
No h/o cough and GE symptoms. 

Attenders tells h/o stoppage of  OHA for 3days, h/o decreased intake of food as he has fever.

H/o altered sensorium since 1 day.
Irrelevant talk,not recognising attenders since this morning .
Able to move all four limbs,No h/o vomitings, head ache, seizures.
Took him to nalgonda hospital, TLC-13,000:POT-5.0:CREATININE:2.9
SHIFTED HERE FOR FURTHUR MANAGEMENT. 
PAST HISTORY - 
H/o TB 2YRS back used ATT for 6 months.
Diagnosed as Type -2 Diabetes mellitus on OHA 1 YR back.
No H/O HTN,CVA,CAD,COVID-19.
PERSONAL HISTORY :

DIET - MIXED,
APPETITE -NORMAL ,
BOWEL MOVEMENT - REGULAR , 
BLADDER MOVEMENTS - REGULAR, ADDICTIONS-H/O  SMOKING 30yrs ago(1 pack per day)- 
ALCOHOL-REGULAR INTAKE OF 180ML  SINCE 30YRS,STOPPED SINCE 2YRS AFTER DIAGNOSIS OF TB.
RECENTLY ALCOHOL INTAKE ON JAN 15,2022.
FAMILY HISTORY:Non-significant.
TREATMENT HISTORY: on OHA SINCE 1YS.
ON ATT FOR 6MONTHS.
 
ON EXAMINATION -

PATIENT IS CONCIOUS , INCOHERENT  NON COOPERATIVE
 NO ICTRUS 
 NO PALLOR
CLUBBING:present.
 NO  CYANOSIS , NO LYMPHADENOPATHY, NO  EDEMA

VITALS - 

TEMPERATURE - 97' F
PULSE RATE - 126BPM
BLOOD PRESSURE - 190/80 MM OF HG 
RESPIRATORY RATE - 28
SPO2 - 97 % AT ROOM AIR
 
GRBS-HIGH.


SYSTEMIC EXAMINATION - 

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : 
BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
DYSPNOEA PRESENT.

P/A - soft,non tenderness 
, no organomegaly


CNS: 
Pt is conscious, inorientation ,non cooperative 
HMF: couldnot  be elicited.

Motor system:unable to move right LL against gravity.

Tone  -   Rt      Lt

U/L        N          N
L/L        ?HYPO          N            

Reflexes:
Biceps,triceps,supinator,knee,ankle:can't be elicited.
    
B/L PLANTAR EXTENSION PRESENT.
O/E NECK STIFFNESS PRESENT,APPEARS TO BE ?SPONDYLOARTHROPATHY.
INVESTIGATIONS:
On 6/2/22


On 7/2/22:




PROVISIONAL DIAGNOSIS:CASE OF ALTERED SENSORIUM SECONDARY TO DKA.

TREATMENT :
1.IVF 2 UNITS NS IV_BOLUS/STAT.
AND THEN IVF NS@100ML/HR
2.INJ.HAI 6U/IV/STAT
3.INJ.HUMAN ACTRAPID 1ML(40U) 
4.INJ.THIAMINE 1AMP IN 100ML NS/IV/OD
5.INJ.OPTINEURON 1 AMP IN 100ML NS/IV/OD
6.GRBS MONITORING-EVERY HOURLY.
7.INJ.MONOCEF 2GM/IV/BD.

LP WAS TRIED AT 1:00AM BUT UNABLE TO TAKE CSF SAMPLES AS PATIENT WAS UNCO-OPERATIVE.





Day-1 SOAP NOTES:
7/2/22
S-PATIENT IS IN ALTERED SENSORIUM. 

O-PATIENT IS CONCIOUS , INCOHERENT  NON COOPERATIVE
 NO ICTRUS 
 NO PALLOR
CLUBBING:present.
 NO  CYANOSIS , NO LYMPHADENOPATHY, NO  EDEMA

VITALS - 

TEMPERATURE - 98.5 F
PULSE RATE - 87BPM
BLOOD PRESSURE - 150/90 MM OF HG 
RESPIRATORY RATE - 20
SPO2 - 99 % AT ROOM AIR
 
GRBS-222mg/dl


SYSTEMIC EXAMINATION - 

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : 
BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
DYSPNOEA PRESENT.

P/A - soft,non tenderness 
, no organomegaly


CNS: 
Pt is conscious, inorientation ,non cooperative 
HMF: couldnot  be elicited.

Motor system:unable to move right LL against gravity.

Tone  -   Rt      Lt

U/L        N          N
L/L        ?HYPO          N            

Reflexes:
Biceps,triceps,supinator,knee,ankle:can't be elicited.
    
B/L PLANTAR EXTENSION PRESENT.
O/E NECK STIFFNESS PRESENT,APPEARS TO BE ?SPONDYLOARTHROPATHY.

A-ALTERED SENSORIUM 2°to DKA

P-LP PROCEDURE 
1.IVF 2 UNITS NS IV_BOLUS/STAT.
AND THEN IVF NS@100ML/HR
2.INJ.HAI 6U/IV/STAT
3.INJ.HUMAN ACTRAPID 1ML(40U) 
4.INJ.THIAMINE 1AMP IN 100ML NS/IV/OD
5.INJ.OPTINEURON 1 AMP IN 100ML NS/IV/OD
6.GRBS MONITORING-EVERY HOURLY.
7.INJ.MONOCEF 2GM/IV/BD

Serum creatinine:2.9
S.electrolytes:Na-142,k-4.1 ,Cl-96
Serum urea-60
Serum osmolarity:316.8
CBP:Hb:11.2
TLC:12,400
N/L/E/M:84/10/4/2
PLT:2.0


Day-2 SOAP NOTES
On 8/2/22

2 D ECHO 

Serum creatinine:2.8
Blood urea:38
FBS:137
HbA1C:7.1
 
ICUCASE UPDATES-BED-6
8/2/22

55YEAR/male

S-C/O ALTERED SENSORIUM-RESOLVED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema
Temp:Afebrile
PR:80bpm
BP:120/80 mm of hg
RR:20cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:SOFT,NONTENDER

A-HHS WITH DIABETIC NEPHROPATHY


P-
1 IVF NS @ UO+75 ML/HR
2.INJ HAI S/C ACC TO GRBS
3.INJ PAN 40 MG/IV/BD
4.INJ THIAMINE 1AMP IN 100MLNS/IV/OD
5 INJ MONOCEF 1GM/IV/BD
6.TAB PCM 650 MG /PO/TID
7.GRBS MONITORING 4TH HOURLY

Day-3 (9/2/22)
FBS:137

ICU CASE UPDATES-BED-6

55YEAR/male

S-C/O ALTERED SENSORIUM-RESOLVED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema
Temp:Afebrile
PR:98bpm
BP:150/100 mm of hg
RR:20cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:SOFT,NONTENDER

A-HHS WITH DIABETIC NEPHROPATHY


P-
1 IVF NS @ UO+75 ML/HR
2.INJ HAI S/C ACC TO GRBS
3.INJ PAN 40 MG/IV/BD
4.INJ THIAMINE 1AMP IN 100MLNS/IV/OD
5 INJ MONOCEF 1GM/IV/BD
6.TAB PCM 650 MG /PO/TID
7.GRBS MONITORING 4TH HOUR

Day-4 soap notes
 
10/2/22

55YEAR/male

S-C/O ALTERED SENSORIUM-RESOLVED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema
Temp:Afebrile
PR:98bpm
BP:150/100 mm of hg
RR:20cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:SOFT,NONTENDER

A-HHS WITH DIABETIC NEPHROPATHY


P-
1 IVF NS @ UO+75 ML/HR
2.INJ HAI S/C ACC TO GRBS
3.INJ PAN 40 MG/IV/BD
4.INJ THIAMINE 1AMP IN 100MLNS/IV/OD
5 INJ MONOCEF 1GM/IV/BD
6.TAB PCM 650 MG /PO/TID
7.GRBS MONITORING 4TH HOUR



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