70 year old DROWSY female with h/o FALL and VOMITINGS

Introduction: This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs. 

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

CASE:

 A 70 year old female home maker since 10-15 years (farmer by occupation) came to the casualty in a drowsy state.

HOPI:

Patient was apparently asymptomatic 10 years back ,then patient had h/o fall for which she went to local hospital where she got diagnosed with Diabetes mellitus and since then she is on OHA medication (glim m2)

4 YEARS BACK
She had h/o fall and went to hospital and got diagnosed with HTN. 
1 session of dialysis was done (indication/cause unknown)
1 MONTH BACK
she developed hypoglycaemia, secondary to OHA’s ,which was resolved later.
4 DAYS BACK
Patient had h/o fall 4 days back ,diagnosed as intertrochanteric fracture of femur of right leg, which was operated(CRIF done).
3 episodes of non-bilious, projectile vomiting associated with abdominal distension and on/off fever two days ago.
On POD 2
Patient was drowsy ,opening eyes to deep pain.

PAST HISTORY:

K/C/O DM since 10 Years & on medication 
K/C/O HTN since 4 Years

GENERAL EXAMINATION: 

O/E : Patient is responding to vocal commands

• Pallor - present

• Icterus  absent

• Cyanosis - absent

• Edema of feet - present

• Lymphadenopathy  - absent

• Clubbing - absent

VITALS:- 

•  BP: 170/90mmhg

•  PR: 98 bpm 

•  RR: 25cpm 

•  Spo2: 95%

•  Grbs: 146

SYSTEMIC EXAMINATION: 

• CVS : S1 and S2 heard, no murmurs heard 

• RS : BAE present

• P/A : soft 

• CNS: Pt is drowsy.

• tone : normal

• Raised echogenecity in both kidneys.

• Multiple small calculi in Gallbladder.

3. CT BRAIN- No abnormalities detected
5. LIVER FUNCTION TESTS- 
6. ABG-
7. SERUM ELECTROLYTES-
8. SERUM CREATININE- 

DAY 2 (13/02/2022)
1. ABG- 
2. RFT-
DAY 3 (14/02/2022)

DAY 4 (15/02/2022)
2. RFT- 

DAY 5 (16/02/2022)
CT ABDOMEN- 

• No abnormality detected

• No features of Small Bowel Obstruction 

• Left sided kidney- small

Uremic encephalopathy with pre renal AKI with POD 4 right femur fracture ? CRIF + PFM with DM and HT

TREATMENT:
On 12/2/22:
1. INJ. Lasix 40mg IV/BD
2. INJ. HAI SC/TID 
3. INJ. CEFTRIAXON 1g/IV/BD
4. INJ. CLINDAMYCIN 600mg/ IV /TID
5.INJ. CLEXANE 20 mg SC/OD
6. INJ. OPTINEURON 1 AMP in 100 ml NS /IV/OD
7.TAB. Amlong 10mg PO /OD
8.IVF NS UO + 30 ml/hr
On 13/2/22:
1. INJ. Lasix 40mg IV/BD
2. INJ. HAI SC/TID 
3. INJ. CEFTRIAXON 1g/IV/BD
4. INJ. CLINDAMYCIN 600mg/ IV /TID
5.INJ. CLEXANE 20 mg SC/OD
6. INJ. OPTINEURON 1 AMP in 100 ml NS /IV/OD
7.TAB. Amlong 10mg PO /OD
8.IVF NS UO + 30 ml/hr

On 14/2/22:
Vitals:

• TEMP: 101 F 

• PR: 92bpm

• BP:-140/60mmhg

• GRBS: 123MG/DL

• CVS: S1S2 heard , no murmurs

• RS : BAE present

• P/A: GUARDING PRESENT

• I/O: 2400/2600

• Stools : not passed

Treatment:

1. INJ. MONOCEF 1GM/IV/BD

1. INJ. LASIX 40 MG IV/BD

1. INJ. HAI SC/TID 

1. INJ. CLINDAMYCIN 600mg/ IV /TID

1. INJ. CLEXANE 20 mg SC/OD

1. TAB. Amlong 10mg PO /OD

1. IVF NS UO+ 30ML/HR

On 15/02.2022
Vitals:

• TEMP:-98.4 F 

• PR:-96 bpm

• BP: 150/ 90mmhg

• GRBS: 245MG/DL

• CVS:-S1S2 heard , no murmurs

• RS : BAE present

• P/A:-GUARDING PRESENT

• I/O: 2100/3200

• Stools : passed 

Treatment:

1. INJ. MONOCEF 1GM/IV/BD

1. INJ. LASIX 40 MG IV/BD

1. INJ. HAI SC/TID 

1. INJ. CLINDAMYCIN 600mg/ IV /TID

1. INJ. CLEXANE 20 mg SC/OD

1. TAB. Amlong 10mg PO /OD

1. IVF NS UO+ 30ML/HR

1. INJ ERYTHROPOIETIN 4000 IU/SC/WEEKLY ONCE

On 16/02/2022

1. INJ. MONOCEF 1GM/IV/BD

1. INJ. PIPTAZ 9.5 MG/ IV

1. INJ. LASIX 40 MG IV/BD

1. INJ. HAI SC/TID 

1. INJ. CLINDAMYCIN 600mg/ IV /TID

1. INJ. CLEXANE 20 mg SC/OD

1. TAB. Amlong 10mg PO /OD

1. IVF NS UO+ 30ML/HR

INVESTIGATIONS:

DAY-1 (12/02/2022)

1. USG ABDOMEN - 

2. ECG - 

4. VENOUS DOPPLER OF RIGHT LOWER LIMB- 

9. D DIMER: 6910ng/ml

BGT: B POSITIVE

Blood urea : 143

ESR :. 140

RBS: 220

APTT: 30 seconds

PT : 15 seconds

INR: 1.11

1. HEMOGRAM- 

                       

2. RFT- 

1. HEMOGRAM- 

PROVISIONAL DIAGNOSIS: 

Treatment:

1. 
   
   
   
   

On 17/02/2022

POD 8:

RIGHT IT FEMUR Fracture- (ORIF+PFN Done )

On examination:

Pt is C/C/C

Abdominal pain - reduced

BP- 120/90 mmHg

PR- 96bpm

3 sessions of hemodialysis done

Investigations: 

1. Hemogram:

• Hb-7.3
• TLC - 29,000
• PLT- 1.5
• D- DIMER - 3280

2. RFT

• UREA - 66
• SERUM CREATININE- 2.3
• URIC ACID-4.6

• Ca- 8.8
• PO4 - 4.2
• Na-139
• K- 3.3
• Cl- 90
• I/o - 2400/3000ml 

Treatment:

1. INJ: PIPTAZ 9.5 MG / IV
2. INJ. LASIX 40 MG IV/BD
3. INJ. HAI SC/TID 
4. INJ. CLINDAMYCIN 600mg/ IV /TID
5. INJ. CLEXANE 20 mg SC/OD
6. TAB. Amlong 10mg PO /OD
7. IVF NS UO+ 30ML/HR
8. 
   
   

On On 18/2/22:

POD 9:

• Right IT femur fracture, CRIF + PFN DONE with DM + HTN
• 3 Sessions of hemodialysis done.

O/E:

Pt is C/C/C 

Abdominal pain and suprapubic pain is present 

Vitals: 

• Afebrile
• BP- 140/100 mm of Hg
• PR: 90 bpm
• CVS: S1 S2 +
• Respiratory system: BAE+
• PER ABDOMEN : Soft and tender
• Grbs : 8Am - 223mg/dl
• I/O: 1700/2100 ml

Treatment:

1. INJ: PIPTAZ 9.5 MG / IV
2. INJ. LASIX 40 MG IV/BD
3. INJ. HAI SC/TID 
4. INJ. CLINDAMYCIN 600mg/ IV /TID
5. INJ. CLEXANE 20 mg SC/OD
6. TAB. Amlong 10mg PO /OD
7. IVF NS UO+ 30ML/HR
8. Inj Erythropoietin 4000IU/ SC / weekly once
9. BP , PR, SPo2, temperature monitoring

Report Abuse