Hyperglycemia resolved Uremia Sepsis -blood cells contain kleibsiella species Hypoalbuminemia ?Nutritional UTI, AKI, denovo DM2,NC/NC Anemia Bed sores(+)Alcohol dependence andTobacco dependence

DR.ROSHINI REDDY

August 11, 2021

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Case scenario:-

75 yr old male, farmer by occupation, came to the casuality with-

CHIEF COMPLAINTS:-

Fever since 10days

Altered sensorium since 6pm on the day of admission

HISTORY OF PAST ILLNESS:-

Patient was apparently asymptomatic until 12months back when they observed patient having decreased interest in doing work and  felt tired throught the day.But the patient was able to move with walking stand and meet relatives and used to ask for food and alcohol .

 OD denies any episodes of cryingspells, low mood, suicidability, loss of appetite, during this period. 

H/o fall from cycle ? 6ys back decreased alcohol and suffered from fracture of hip(femur neck ) right side didn't visit hospital had local treatment since then staying at home and stopped field work. 

Patient was able to do his daily activities can also used to ride cycle occasionally.

From 1 yr patient became more lethargic, Not interacting actively with the family members, spending more time on bed.

Bed Sores Over B/L back part of the legs

10 days back patient developed fever with tremors in hands and jaws and muttering of words due to pain with decreased interaction. Since 2days with ulcers on back so, they took him to local hospital and was treated later patient felt better, able to speak properly and ate food.

After 4 days patient has similar episodes with fever and was brought to here to hospital.

H/o Alcohol use since 30yrs, decreased consumption since 2 months, 90ml (-3 units) per week. 

Tobacco use since 30yrs( consumes 10-15 beedis per day)

H/o disinhibited behaviour since 2 months.

No h/o self talking, self laughing, suspicious memory disturbances, irritability, repetitve thoughts.

PAST HISTORY:-

N/K/C DIABETES, HYPERTENSION, ASTHMA, TB, EPILEPSY.

No H/O any surgeries in the past.

FAMILY HISTORY:-

Not significant

PERSONAL HISTORY:-

Diet-Mixed

Appetite-normal

Bowel and bladder movements- Regular

Sleep- Adequate

GENERAL EXAMINATION:-

Patient is conscious and co operative, 

Drowsy but arousable

Oriented to person, 

place -,

 time -,

 Registration -,

 attention -, 

Recall -

Moderately built and moderately nourished.

Consent obtained

On examination:

No pallor

No icterus

No cyanosis

No clubbing

No lymphadenopathy

No edema.

Vitals:-

Temp- afebrile.

PR:96 BPM.

RR: 16 CPM.

Bp: 80/60 mm Hg

Spo2 : 98%

GRBS 196 MG%.

SYSTEMIC EXAMINATION:-

A. Cardiovascular system 

S1 S2 HEARD

NO MURMURS.

B. Respiratory system 

NVBS heard

 BAE +

 TRACHEA CENTRAL.

C. Per abdominal examination 

SOFT

NON TENDER

NON DISTENDED.

D.CNS EXAMINATION:-

1. Higher Mental Function:-

Drowsy but arousable

Oriented to person, place -, time -, Registration -, attention -, Recall -

Language - spontaneous speech , - fluency, - comprehension

2. Cranial nerves - all cranial nerves 

                               - gag reflex

                               - vulva position

3. Motor system - attitude -

                                       Rt.                 Lt.  

          

          Tone.     UL.         -                      -

                         LL.       hypo.                -

           

          Power.   UL.           -                     -  

                         LL.            -                    -

        Reflexes.  B               +                    +

                          T.                -                     -

                          S.                 -                    -

                          K.                 -                     -

                          A.                  -                    -

                     Plantars 

4. Sensory system - Couldn't be done

                                     Deep pain +

                                     Superficial pain +

5. Cerebellar system - couldn't be done

6. No signs of meningial irritation/ meningitis

OD denies any psychiatric illness in family.

Motor System Examination :- Patient is lying on bed in upright position

Eye To Eye Examination - , 

BILATERAL swelling of arms

Psycho Motor Activity:-DECREASED

Rapport established with difficulty

Speech 

Tone, Volume and Rate- DECREASED,

Reaction Time INCREASED.

--able to answer on repeated questioning by relatives

--mood and other Mental status examination-could not be established.

BEDSORES

INVESTIGATIONS:-

12/08/21

Hemogram report

Ultrasound report 

HIV 1/2 rapid test

Anti HCV antibodies

RFT

RTPCR

ESR

Urine test for ketone bodies

Complete urine examination 

Liver function test

2D Echo report 

Good lv systolic potential + ( EF-58 percentage) 

No Rwma ,No ms /as

Mild Lvh + sclerotic av

Mild mr+ trivial ar+

Diastolic dysfunction +

IVC dialated (1.45cms) normal

 No pe/lv clot

Random blood sugar

 

ABG Report

X Ray

13/08/21

RFT

Hemogram report 

X ray

14/8/21

PSYCHIATRIC CROSS CONSULTATION:-

This is the case of 75yr old male diagnosed ?hyperglycemia, hypoalbuminenia, UTI, AKI,denovo DM2, With anemia and bed sores reffered i/v/o chronic illness which could be psychiatric manifestation as patient c/o of pain and experiencing distress on evaluation.

-- History noted from OD(objective data)

--Patient is lying on bed with Ryles tube and IV cannuli responding with only monosyllable on commands

--Unable to move both Upper Limbs and Lower limbs

OD denies any psychiatric illness in family.

Motor System Examination :- Patient is lying on bed in upright position

Eye To Eye Examination - , 

BILATERAL swelling of arms

Psycho Motor Activity:-DECREASED

Rapport established with difficulty

Speech 

Tone, Volume and Rate- DECREASED,

Reaction Time INCREASED.

--able to answer on repeated questioning by relatives

--mood and other Mental status examination-

--IMPRESSION- adjustment issue secondary Alcohol dependence currently  abstinent due to illness

*Tobacco dependence currently ? withdrawal

Rx-

patient attenders councelled

T.SERTA 25 mg OD every morning

LOSENGES 2mg sos

 

PROVISINAL DIAGNOSIS:-

Fever under evaluation

Altered sensorium

Hyperglycemia

TREATMENT:-

Day-1

INJ HAI IV ( 39ml NS + HAI)@ 6ml/hr followed by infusion according to Alog-1

1 hrly GRBS

INJ PIPTAZ 4.5gm IV stat followed by INJ PIPTAZ 2.25gm I've stat

INJ OPTINEURON 1 Amo in 100ml NS/IV/OD

Protein powder -2tsp in 1 glass of milk /twice a day in rules tube

Patient feeds milk with protein powder - 100 my every 2 ND hrly and plain water every hrly.

Hrly GRBS charting 

INJ NORADRENALINE( 2amp in 50ml NS) @2ml /hr to maintain MAP >or = 6

Day -2

1.IVF 10NS @75 ml/hr

2.INJ PIPITAZ 2.25gm/IV/TID

3.INJ OPTINEURON 1amp in 100ml NS

4.TAB OROFER -XT/PO/OD

5.TAB LASIX 20mg/PO/OD 

6.Protein -x-powder -2tsp in 1 glass of milk /Rt feeds 2nd hrly

 Rt-plain water - 200ml /hrly

7.INJ HALI /SC/TID 

8.PR/BP/RR/SpO2 charting 2nd hourly

9. GRBS charting 6th hourly

10. Inj TRAMADOL 1 amp in 100 ml NS IV/OD

11.TAB VITRACET 1/2 tab/RT

Day -3

• 1. IVF NS @ 75ml/hr
• 2. Inj PIPTAZ 2.25gm/IV/TID
• 3. Inj Optineuron 1 amp in 100ml NS IV/OD
• 4. Tab Orofer - XT/RT/OD
• 5. Tab Lasix 20mg/RT/OD(if SBP > 100 mg 8am---- x ---- x
• 6. Protein-X powder 2tsp in 1 glass of milk/ RT feed 2nd hourly
• 7. Inj HAI/SC/TID after informing Sugars to ICU Ph
• 8. Inj Tramadol 1 amp in 100 ml NS/IV/OD
• 9. Tab Ultracet 1/2 tablet/RT/QID1/2----1/2----1/2----1/2
• 10. Two egg whites/day
• 11. Bp/PR/RR/SPO2 Charting 2nd hourly
• 12. GRBS Charting 6th hourly 8am----2pm----8pm----2am

Day -4-

• IVF 10 NS @75 ml/hr
• Inj.Piptaj 2.25 gm/IV/T
• Inj.Opti Neuron 1 amp in 100ml NS/N/OD
• TAB.Fluconazole 150 mg/PO/OD
• TAB. OROFER RT/OD
• TAB.Lasix 20 mg/RT/OD
• Protein-x powder 2 tbsp in 1 glass of milk,RT feed 2 nd hourly RT plain water-200 ml hourly
• Inj.HAI /SC/TID 
• Inj.TRAMADOL lamp in 100 pal NS/IV/OD
• TAB.ULTRACET 1/2 tab/RT/OD 
• 2 egg whites/day
• BP/PR/RR/Spo2 charting 2nd hourly
• GRBS charting 6th hourly 8 AM-2 PM-8 PM-2 AM

DAY-5

IVF 10NS @75ml/hrly

INJ PIPTAZ 2.25 gm IV/TID

INJ OPTINEURON 1amp in 100 ml NS/ IV /OD

TAB FLUCONAZOLE 150mg PO/OD

TAB OROFER  (5) RT/OD

TAB LASIX 20mg RT /OD

Protein-x powder 2 tbsp in 1 glass of milk

TAB GLICIAZIDE PO/OD (1/2 tab) 

I/O CHARTING

DISCHARGE SUMMARY

Case:-

75 yr old male came to the casuality with c/o fever since 10 days,Altered sensorium since 6:00pm.

CHIEF COMPLAINTS:-Fever since 10days,Altered sensorium since 6pm.

HISTORY OF PRESENT ILLNESS:-

Patient was apparently alright till 10 days back then he had fever insidious onset, low grade Continous, Relieved on taking medication, Not associated with chills and Rigors.

Today morning patient was talking normally from 6 pm.patient was just muttering words.

HISTORY OF PAST ILLNESS:-

Patient was farmer by occupation; one day 6 yrs back patient drank Alcohol, fell from cycle, got fractured in the Right femur neck fracture got treated from local RMP.lethargic, Not interacting actively with the family members, spending more time on bed.

Bed Sores Over B/L back part of the legs

PAST HISTORY:-

No h/o similar complaints before.

No known comorbidities.

GENERAL EXAMINATION:-

No pallor,No icterus,No cyanosis,No clubbing

No lymphadenopathy,No edema.

Vitals:-

Temp- afebrile.

PR:96 BPM.

RR: 16 CPM.

Bp: 80/60 mm Hg

Spo2 : 98%

GRBS 196 MG%.

SYSTEMIC EXAMINATION:-

A. Cardiovascular system 

S1 S2 HEARD,NO MURMURS.

B. Respiratory system 

NVBS heard,BAE +,TRACHEA CENTRAL.

C. Per abdominal examination 

SOFT,NON TENDER,NON DISTENDED.

D. Central nervous system 

CONSCIOUS,NO SIGNS OF MENINGEAL IRRITATION.

**Reflexes:-

                   RT. LT.

BICEPS. + +

TRICEPS. + +

SUPINATOR. + +

KNEE. + +

ANKLE. + +

PLANTAR: FLEXOR.

PROVISINAL DIAGNOSIS:-

Fever under evaluation

Altered sensorium

Hyperglycemia

SOAP NOTES

Day -1

Subjective-

C/oFever

C/o altered sensorium 

Objective:-

Temperature 

At 4am 98 F

At 8am 37.5 C

BP 80/60 mmHg

PR 96/mins

RR: 16 CPM.

Assessment :-

Hyperglycemia 

Fever under evaluation

Altered sensorium

Plan of care:-

1.INJ HAI IV ( 39ml NS + HAI)@ 6ml/hr followed by infusion according to Alog-1

1 hrly GRBS

2.INJ PIPTAZ 4.5gm IV stat followed by INJ PIPTAZ 2.25gm I've stat

3.INJ OPTINEURON 1 Amo in 100ml NS/IV/OD

4.Protein powder -2tsp in 1 glass of milk /twice a day

5.Patient feeds milk with protein powder - 100 my every 2 ND hrly and plain water every hrly.

6.Hrly GRBS charting 

7.INJ NORADRENALINE( 2amp in 50ml NS) @2ml /hr to maintain MAP >or = 6

Day-2

Subjective:-

C/o fever

C/o altered sensorium

Objective:-

Temparature-

At 4am -38 C

At 8am -37.5 C

BP-80/50

PR-96/min

RR-21 cpm

Assessment :-

Hyperglycemia resolved

Right lobe pneumonia 

Hypoalbuminemia ?Nutritional 

UTI, AKI, denovo DM2,

NC/NC Anemia 

Bed sores

Plan of care:-

1.IVF 10NS @75 ml/hr

2.INJ PIPITAZ 2.25gm/IV/TID

3.INJ OPTINEURON 1amp in 100ml NS

4.TAB OROFER -XT/PO/OD

5.TAB LASIX 20mg/PO/OD 

6.Protein -x-powder -2tsp in 1 glass of milk /Rt feeds 2nd hrly

 Rt-plain water - 200ml /hrly

7.INJ HALI /SC/TID 

8.PR/BP/RR/SpO2 charting 2nd hourly

9. GRBS charting 6th hourly

10. Inj TRAMADOL 1 amp in 100 ml NS IV/OD

11.TAB VITRACET 1/2 tab/RT

SOAP NOTES Day-3

Subjective:-

C/o fever 

c/o altered sensorium 

Objective :-

Tempature-

4-12 am -37.5 C

4-8pm-98.5 F

12pm-37.5 C

BP 110/70mmHg

PR 92 bpm

Assessment:-

Hyperglycemia resolved

Shorts not paused

Plan of care:-

1. IVF NS @ 75ml/hr

2. Inj PIPTAZ 2.25gm/IV/TID

3. Inj Optineuron 1 amp in 100ml NS IV/OD

4. Tab Orofer - XT/RT/OD

5. Tab Lasix 20mg/RT/OD(if SBP > 100 mg 8am---- x ---- x

6. Protein-X powder 2tsp in 1 glass of milk/ RT feed 2nd hourly

7. Inj HAI/SC/TID after informing Sugars to ICU Ph

8. Inj Tramadol 1 amp in 100 ml NS/IV/OD

9. Tab Ultracet 1/2 tablet/RT/QID1/2----1/2----1/2----1/2

10. Two egg whites/day

11. Bp/PR/RR/SPO2 Charting 2nd hourly

12. GRBS Charting 6th hourly 8am----2pm----8pm----2am

 SOAP NOTES-Day-4

Subjective:-

c/o fever and altered sensorium

Objective :-

Temperature-

4-8am 37.5 C

8-12am- 98.5-99 F

BP 100/70mmHg

PR 84bpm

Assessment:-

Hyperglycemia resolved 

Back pain

Plan of care:-

Rx:

IVF 10 NS @75 ml/hr

Inj.Piptaj 2.25 gm/IV/T

Inj.Opti Neuron 1 amp in 100ml NS/N/OD

TAB.Fluconazole 150 mg/PO/OD

TAB. OROFER RT/OD

TAB.Lasix 20 mg/RT/OD

Protein-x powder 2 tbsp in 1 glass of milk,RT feed 2 nd hourly RT plain water-200 ml hourly

Inj.HAI /SC/TID 

Inj.TRAMADOL lamp in 100 pal NS/IV/OD

TAB.ULTRACET 1/2 tab/RT/OD 

2 egg whites/day

BP/PR/RR/Spo2 charting 2nd hourly

GRBS charting 6th hourly 8 AM-2 PM-8 PM-2 AM

Soap notes day-5

 Subjective :-

 

 C/o fever and altered sensorium 

 

Objective:-

Temperature-

4-8am-37.5 C

BP-100/70 mmHg

PR-81bpm

Assessment:-

 

Hyperglycemia resolved 

Uremia

 Sepsis -blood cells contain kleibsiella species 

Hypoalbuminemia ?Nutritional 

UTI, AKI, denovo DM2,

NC/NC Anemia 

Bed sores(+)

Alcohol dependence and

Tobacco dependence 

Plan of care:-

IVF 10NS @75ml/hrly

INJ PIPTAZ 2.25 gm IV/TID

INJ OPTINEURON 1amp in 100 ml NS/ IV /OD

TAB FLUCONAZOLE 150mg PO/OD

TAB OROFER (5) RT/OD

TAB LASIX 20mg RT /OD

Protein-x powder 2 tbsp in 1 glass of milk

TAB GLICIAZIDE PO/OD (1/2 tab) 

I/O CHARTING