Project and case 1 summary:
CASE 1
From a PRESENTATION
BY
Dr.Narsimha Reddy
FINAL YEAR POSTGRADUATE
DEPT OF GENERAL MEDICINE in an integrated session on 17/07/2024
75 year old male was brought to casuality on 27/06/2024 with complaints of
Loose stools since 2 days
Altered sensorium since 2 days
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 2 days ago then he developed
loose stools 4 episodes , large quantity ,watery in consistency , non mucoid, non blood tinged , non foul smelling.
Then he developed altered sensorium.
No history of nausea ,vomiting, pain abdomen.
No history of fever , headache .
No history of chest pain , palpitations , orthopnea ,PND.
No history of shortness of breath ,cough ,cold.
PAST HISTORY
No history of similar complaints in the past.
K/C/O HYPERTENSION since 5 years and on tab TELMISARTAN 40 mg, tab METOPROLOL 50 mg .
K/C/O DIABETES MELLITUS since 5 years and on tab GLIMEPIRIDE 2mg , tab METFORMIN 500 mg
No history of Asthma, tuberculosis ,coronary artery disease , cerebrovascular accident.
Appetite - Decreased
Diet –Mixed
Bowel – Increased bowel movements
Bladder - Normal
Sleep - Adequate
Addictions –Nil
No known allergies
GENERAL EXAMINATION
Patient is drowsy but arousable.
GCS- E2V2M4
Moderately built and moderately nourished
JVP-not raised
Dry tongue , Reduced Skin Turgor .
No pallor , icterus, cyanosis, clubbing, pedal edema and lymphadenopathy.
Vitals on the day of admission
Temp - 98.6°F
PR -135 bpm
Bp - 110/70 mmHg measured in left arm in supine position
RR- 28 cpm
SPO2 - 99% at room air
SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM
Handedness – Right handed
Higher Mental Functions – couldn’t be elicited
Pupils – Bilaterally normal in size and reactive to light
Corneal reflex – present
Conjunctival reflex – present
Gag reflex - present
Jaw jerk - absent
Other cranial nerves couldn’t elicited
MOTOR SYSTEM:
RIGHT LEFT
Bulk - UL normal normal
LL normal normal
Tone - UL normal normal
LL normal normal
POWER RIGHT LEFT
UL couldn’t be elicited
LL couldn’t be elicited
REFLEXS biceps 2+ 2+
triceps 2+ 2+
supinator 2+ 2+
knee 2+ 2+
Ankle 2+ 2+
plantars flexor flexor
Sensory sysyem - Couldn’t Be Elicited
Cerebellar signs - Couldn’t Be Elicited
No Signs Of Meningeal Irritation
Examination Of Spine And Cranium Normal
No Thickened Peripheral Nerves
No Carotid Bruit Heard
RESPIRATORY SYSTEM
Chest – elliptical in shape .
Trachea – central.
Chest expansion – bilaterally equal expansion .
Auscultation – bilaterally normal vesicular breath sounds heard , no added sounds.
CARDIOVASCULAR SYSTEM
Apex beat is felt in left 5th intercostal space half inch medial to mid clavicular line
S1,S2 heard.
No murmurs
GASTROINTESTINAL SYSTEM
Per Abdomen –Scaphoid In Shape
Soft
No Organomegaly
Bowel Sounds Heard
PROVISIONAL DIAGNOSIS
ALTERED SENSORIUM SECONDARY TO ? DYSELECTROLYTEMIA
INVESTIGATIONS on the day of admission
CHEST XRAY
ECG
2D ECHO
USG ABDOMEN AND PELVIS
FINAL DIAGNOSIS
TYPE 1 RESPIRATORY FAILURE
CARDIOGENIC SHOCK WITH ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE SECONDARY TO CORONARY ARTERY DISEASE.
SEPTIC SHOCK SECONDARY TO ACUTE GASTROENTERITIS
ACUTE KIDNEY INJURY SECONDARY TO GASTROENTERITIS
HYPONATREMIA SECONADRY TO GASTROINTESTINAL LOSS
CHRONIC LIVER DISEASE
HYPERTENSION
TYPE 2 DIABETES MELLITUS
GRADE 2 BED SORE
DAY - 1
A 75 Yr Old Male With History Of Hypertension And Diabetes Mellitus Since 5 Years , Came To Casualty With Complaints Of 4 Epsiodes Of Loose Stools, Altered Sensorium Since 2 Days . On Initial Evaluation
Ecg Showed - Atrial Fibrillation With Fast Ventricular Rate For Which 1mg Metoprolol Iv/Stat Was Given And Rate Was Controlled.
Ryles Tube Was Placed And Started On RT Feeds - 100ml Milk 4th Hrly , 100 Ml Water 2nd Hrly.
Serum Electrolytes Showed - Sodium-126,potassium-4.2,
Hemogram showed- Hb-12, TLC-15,400 ,(N/L/E/M/B-87/06/00/07/00) , Plt-1.69.patient was started on INJ CEFTRIAXONE 1GM IV/BD
DAY 2
GCS was E3V3M5,
0.9 % NS infusion continued as serum electrolytes report showed Na:126meq/L , K: 4.2meq/L , Cl : 83meq/L.
2D ECHO SHOWED RWMA , LAD TERRITORY Hypokinesia , EF= 51%, Fair LV systolic function.
ECG changes of ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE Was Persistent And Was Started On AMIODARONE INFUSION 1mg/min for 6hrs followed by 0.5mg/min for 18 hrs AND ANTI COAGULANTS.
I/v/o Hypotension patient was started on INOTROPE support .
Repeat serum electrolytes showed : Na:117 meq/l , K : 4.3meq/l , Cl: 91meq/l was started on 3% NS INFUSION .
DAY 3
Serum electrolytes report showed Na : 132meq , K:3.8 , Cl :99 meq . 3% NS infusion stopped.
GCS improved to E4V5M6.
Hemogram showed : Hb:12.4gm% , TLC:18,400 cell/cumm , Plt :2.3lakhs so antibiotic was escalated to Inj PIPTAZ 2.25gms IV/QID.
ABG showed PH: 7.36 , Pco2:12 , Po2: 93.5, HCO3: 6.7 so 50meq of sodium bicarbonate was given .
I/V/O Persistent ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE AND HYPOTENSION , CARDIOLOGIST advice was taken , STARTED ON DIGOXIN, AMIADARONE, DILTIAZEM tablets and INOTROPES .
INJ LASIX 40MG was given i/v/o decreased urine output
AT 8PM GCS dropped to E4V2M6 and serum electrolytes report showed : Na :126meq/l , K ;4.2 meq/l ,Cl : 98 meq/l so, 3% NS was started .
DAY -4
GCS-E4V2M6.
Serum electrolytes report showed Na: 127meq/l , K: 3.8 meq/l , Cl : 98meq/l . So 3% NS was continued.
I/V/O persistent hypotension , central line was placed and started on dual inotropic support as advised by cardiologist.
Repeat serum electrolytes showed Na : 122meq/l , K : 3.4meq/l , Cl: 98meq/l , so TOLVAPTAN was started.
Patient developed Grade II Bedsore on Bilateral Gluteal Region and surgery opinion was taken and managed accordingly.
DAY -5
GCS- E4V2M6
Serum electrolytes report showed Na: 122meq/l , K: 3.5meq/l , Cl: 97meq/l .
ON CNS EXAMINATION RIGHT PLANTAR WERE MUTE , LEFT PLANTAR WERE FLEXOR AND MRI BRAIN was done and showed DIFFUSE CREBRAL ATOPHY .
I/V/O ATRIAL FIBRILLATION WITH CONTROLLED VENTRICULAR RATE AND PERSISTENT HYPOTENSION, CARDILOGIST review was taken and advised to stop DILTIAZEM, DIGOXIN AND NOR ADRENALINE and was started on VASOPRESSIN.
DAY 6
GCS –E3V2M6 .
Serum electrolytes report showed Na: 130meq/l , K: 3.1meq/l , Cl: 102 meq/l so syp POTKLOR was started.
24HR Urinary Electrolytes report showed : Na : 152 , K: 12 ,Cl : 390.
REVIEW 2D ECHO SHOWED D SHAPED LV, PARADOXICAL MS, EF:53% FAIR LV FAIR LV SYSTOLIC FUNCTION AND GRADE 1 DIASTOLIC DYSFUNCTION.
DAY 7
GCS –E3V2M5 .
Serum electrolytes report showed Na: 129meq/l , K: 3.0meq/l , Cl: 101 meq/l.
Patient was still drowsy and ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE AND HYPOTENSION still persistent
DAY 8 -9
On day -8 the condition of the patient was still same and serum electrolytes report showed : Na: 131meq/l , K : 3.6meq/l , Cl : 101meq/l .
On day -9 the condition of the patient was still same and serum electrolytes report showed : Na: 138meq/l , K :4.4 meq/l , Cl :102 meq/l .
Patient developed sudden bradycardia fall in saturation, emergency intubation was done and cpr was initiated simultaneously. despite all the effort the patient could not be revived and was declared dead as ecg showed Isoelectric line on 06.07.24 at 9:20am
HEMOGRAM
RFT
RFT
URINARY ELECTROLYTES [SPOT]
URINARY ELECTROLYTES [24 HOUR]
ABG
LFT
CULTURE AND SENSITIVITY REPORTS
BY
Dr.Narsimha Reddy
FINAL YEAR POSTGRADUATE
DEPT OF GENERAL MEDICINE in an integrated session on 17/07/2024
75 year old male was brought to casuality on 27/06/2024 with complaints of
Loose stools since 2 days
Altered sensorium since 2 days
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 2 days ago then he developed
loose stools 4 episodes , large quantity ,watery in consistency , non mucoid, non blood tinged , non foul smelling.
Then he developed altered sensorium.
No history of nausea ,vomiting, pain abdomen.
No history of fever , headache .
No history of chest pain , palpitations , orthopnea ,PND.
No history of shortness of breath ,cough ,cold.
PAST HISTORY
No history of similar complaints in the past.
K/C/O HYPERTENSION since 5 years and on tab TELMISARTAN 40 mg, tab METOPROLOL 50 mg .
K/C/O DIABETES MELLITUS since 5 years and on tab GLIMEPIRIDE 2mg , tab METFORMIN 500 mg
No history of Asthma, tuberculosis ,coronary artery disease , cerebrovascular accident.
Appetite - Decreased
Diet –Mixed
Bowel – Increased bowel movements
Bladder - Normal
Sleep - Adequate
Addictions –Nil
No known allergies
GENERAL EXAMINATION
Patient is drowsy but arousable.
GCS- E2V2M4
Moderately built and moderately nourished
JVP-not raised
Dry tongue , Reduced Skin Turgor .
No pallor , icterus, cyanosis, clubbing, pedal edema and lymphadenopathy.
Vitals on the day of admission
Temp - 98.6°F
PR -135 bpm
Bp - 110/70 mmHg measured in left arm in supine position
RR- 28 cpm
SPO2 - 99% at room air
SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM
Handedness – Right handed
Higher Mental Functions – couldn’t be elicited
Pupils – Bilaterally normal in size and reactive to light
Corneal reflex – present
Conjunctival reflex – present
Gag reflex - present
Jaw jerk - absent
Other cranial nerves couldn’t elicited
MOTOR SYSTEM:
RIGHT LEFT
Bulk - UL normal normal
LL normal normal
Tone - UL normal normal
LL normal normal
POWER RIGHT LEFT
UL couldn’t be elicited
LL couldn’t be elicited
REFLEXS biceps 2+ 2+
triceps 2+ 2+
supinator 2+ 2+
knee 2+ 2+
Ankle 2+ 2+
plantars flexor flexor
Sensory sysyem - Couldn’t Be Elicited
Cerebellar signs - Couldn’t Be Elicited
No Signs Of Meningeal Irritation
Examination Of Spine And Cranium Normal
No Thickened Peripheral Nerves
No Carotid Bruit Heard
RESPIRATORY SYSTEM
Chest – elliptical in shape .
Trachea – central.
Chest expansion – bilaterally equal expansion .
Auscultation – bilaterally normal vesicular breath sounds heard , no added sounds.
CARDIOVASCULAR SYSTEM
Apex beat is felt in left 5th intercostal space half inch medial to mid clavicular line
S1,S2 heard.
No murmurs
GASTROINTESTINAL SYSTEM
Per Abdomen –Scaphoid In Shape
Soft
No Organomegaly
Bowel Sounds Heard
PROVISIONAL DIAGNOSIS
ALTERED SENSORIUM SECONDARY TO ? DYSELECTROLYTEMIA
INVESTIGATIONS on the day of admission
CHEST XRAY
ECG
2D ECHO
USG ABDOMEN AND PELVIS
FINAL DIAGNOSIS
TYPE 1 RESPIRATORY FAILURE
CARDIOGENIC SHOCK WITH ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE SECONDARY TO CORONARY ARTERY DISEASE.
SEPTIC SHOCK SECONDARY TO ACUTE GASTROENTERITIS
ACUTE KIDNEY INJURY SECONDARY TO GASTROENTERITIS
HYPONATREMIA SECONADRY TO GASTROINTESTINAL LOSS
CHRONIC LIVER DISEASE
HYPERTENSION
TYPE 2 DIABETES MELLITUS
GRADE 2 BED SORE
DAY - 1
A 75 Yr Old Male With History Of Hypertension And Diabetes Mellitus Since 5 Years , Came To Casualty With Complaints Of 4 Epsiodes Of Loose Stools, Altered Sensorium Since 2 Days . On Initial Evaluation
Ecg Showed - Atrial Fibrillation With Fast Ventricular Rate For Which 1mg Metoprolol Iv/Stat Was Given And Rate Was Controlled.
Ryles Tube Was Placed And Started On RT Feeds - 100ml Milk 4th Hrly , 100 Ml Water 2nd Hrly.
Serum Electrolytes Showed - Sodium-126,potassium-4.2,
Hemogram showed- Hb-12, TLC-15,400 ,(N/L/E/M/B-87/06/00/07/00) , Plt-1.69.patient was started on INJ CEFTRIAXONE 1GM IV/BD
DAY 2
GCS was E3V3M5,
0.9 % NS infusion continued as serum electrolytes report showed Na:126meq/L , K: 4.2meq/L , Cl : 83meq/L.
2D ECHO SHOWED RWMA , LAD TERRITORY Hypokinesia , EF= 51%, Fair LV systolic function.
ECG changes of ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE Was Persistent And Was Started On AMIODARONE INFUSION 1mg/min for 6hrs followed by 0.5mg/min for 18 hrs AND ANTI COAGULANTS.
I/v/o Hypotension patient was started on INOTROPE support .
Repeat serum electrolytes showed : Na:117 meq/l , K : 4.3meq/l , Cl: 91meq/l was started on 3% NS INFUSION .
DAY 3
Serum electrolytes report showed Na : 132meq , K:3.8 , Cl :99 meq . 3% NS infusion stopped.
GCS improved to E4V5M6.
Hemogram showed : Hb:12.4gm% , TLC:18,400 cell/cumm , Plt :2.3lakhs so antibiotic was escalated to Inj PIPTAZ 2.25gms IV/QID.
ABG showed PH: 7.36 , Pco2:12 , Po2: 93.5, HCO3: 6.7 so 50meq of sodium bicarbonate was given .
I/V/O Persistent ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE AND HYPOTENSION , CARDIOLOGIST advice was taken , STARTED ON DIGOXIN, AMIADARONE, DILTIAZEM tablets and INOTROPES .
INJ LASIX 40MG was given i/v/o decreased urine output
AT 8PM GCS dropped to E4V2M6 and serum electrolytes report showed : Na :126meq/l , K ;4.2 meq/l ,Cl : 98 meq/l so, 3% NS was started .
DAY -4
GCS-E4V2M6.
Serum electrolytes report showed Na: 127meq/l , K: 3.8 meq/l , Cl : 98meq/l . So 3% NS was continued.
I/V/O persistent hypotension , central line was placed and started on dual inotropic support as advised by cardiologist.
Repeat serum electrolytes showed Na : 122meq/l , K : 3.4meq/l , Cl: 98meq/l , so TOLVAPTAN was started.
Patient developed Grade II Bedsore on Bilateral Gluteal Region and surgery opinion was taken and managed accordingly.
DAY -5
GCS- E4V2M6
Serum electrolytes report showed Na: 122meq/l , K: 3.5meq/l , Cl: 97meq/l .
ON CNS EXAMINATION RIGHT PLANTAR WERE MUTE , LEFT PLANTAR WERE FLEXOR AND MRI BRAIN was done and showed DIFFUSE CREBRAL ATOPHY .
I/V/O ATRIAL FIBRILLATION WITH CONTROLLED VENTRICULAR RATE AND PERSISTENT HYPOTENSION, CARDILOGIST review was taken and advised to stop DILTIAZEM, DIGOXIN AND NOR ADRENALINE and was started on VASOPRESSIN.
DAY 6
GCS –E3V2M6 .
Serum electrolytes report showed Na: 130meq/l , K: 3.1meq/l , Cl: 102 meq/l so syp POTKLOR was started.
24HR Urinary Electrolytes report showed : Na : 152 , K: 12 ,Cl : 390.
REVIEW 2D ECHO SHOWED D SHAPED LV, PARADOXICAL MS, EF:53% FAIR LV FAIR LV SYSTOLIC FUNCTION AND GRADE 1 DIASTOLIC DYSFUNCTION.
DAY 7
GCS –E3V2M5 .
Serum electrolytes report showed Na: 129meq/l , K: 3.0meq/l , Cl: 101 meq/l.
Patient was still drowsy and ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE AND HYPOTENSION still persistent
DAY 8 -9
On day -8 the condition of the patient was still same and serum electrolytes report showed : Na: 131meq/l , K : 3.6meq/l , Cl : 101meq/l .
On day -9 the condition of the patient was still same and serum electrolytes report showed : Na: 138meq/l , K :4.4 meq/l , Cl :102 meq/l .
Patient developed sudden bradycardia fall in saturation, emergency intubation was done and cpr was initiated simultaneously. despite all the effort the patient could not be revived and was declared dead as ecg showed Isoelectric line on 06.07.24 at 9:20am
HEMOGRAM
RFT
RFT
URINARY ELECTROLYTES [SPOT]
URINARY ELECTROLYTES [24 HOUR]
ABG
LFT
CULTURE AND SENSITIVITY REPORTS
UDLCO PaJR CBBLE team based learning:
[17/07, 08:50] moderator: What do you mean power couldn't be elicited? Wasn't he moving his limbs even in his altered sensorium state?
Also what do you write in CNS examination for altered sensorium? Hmf couldn't be elicited?
[17/07, 08:46] : Where's the ABG on 27/6/24 in this chart? Why not included that? How do you explain the presence of metabolic acidosis, respiratory alkalosis and metabolic alkalosis in it? Have you checked the delta gap?
[17/07, 08:48] : What do you mean power couldn't be elicited? Wasn't he moving his limbs even in his altered sensorium state?
Also what do you write in CNS examination for altered sensorium? Hmf couldn't be elicited?
[17/07, 08:49]: How did we gain by testing the urinary electrolytes?
[17/07, 09:06] : Sir Can't it be Respiratory alkalosis due to Increased RR & Compensated by Metabolic Acidosis?
[17/07, 09:07] : I mean We can't Elicit for Power with Resistance Sir
[17/07, 09:14] moderator: Is the metabolic acidosis compensation adequate? If not why? What generally happens in similar respiratory alkalosis patients?
[17/07, 09:15] moderator: But at least against gravity power was noted?
[17/07, 09:36]: For every Drop in Pco2 by 10 Hco3 drops by 2 in Acute & 4 in Chronic Sir ......But here Bicarb drop is More Sir
[17/07, 09:37]: Change in Anion Gap is 17 Sir & Change in Bicarb is 19 Sir
[17/07, 09:38] : Indicating the presence of Normal AG Metabolic Acidosis Sir
17/07, 09:40] moderator: How do we explain that?
[17/07, 09:39] : Yes Sir ....He was able to move against gravity
[17/07, 09:40] moderator: So automatically in your assessment you can document grade 3 power was at least present?
[17/07, 11:02] Rakesh Biswas: [17/07, 09:40] moderator: How do we explain that?
[17/07, 09:43] : Can't we explain that with Diarrhoea he had Sir ??
[17/07, 09:45] : Or there can be chance of RTA /Adrenal Insufficiency also Sir ??
[17/07, 10:07] moderator: Review the ABG diarrhoea thesis from narketpally here 👇
https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006004-thesis.html?m=1
And let me know if your patient's sequence of events has been described in all the patients of diarrhoea logged in the 2019-21 thesis.
[17/07, 10:10]t: I guess we had another thesis on bicarb supplementation on acidosis as well
[17/07, 10:24] CBBLE: Yes can find it here👇
https://medicinedepartment.blogspot.com/2022/05/links-to-ug-and-pg-university-exam.html?m=0
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