90yr old man with altered sensorium
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High grade fever since 1 week
Unable to sit since 1 week
Unable to walk since 1 week
Abdominal distension since 5 days
Unable to pass stools since 5 days
Unable to speak since 3 days
Reduced urine output since 1 day
Altered sensorium since 1 day
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 1week ago
Then he had high grade,intermittent fever associated with chills and generalised weakness.He was unable to sit and walk since then.He was unable to pass stools since 5days and There was abdomen distension since 5days. 1 week back the patient's sons found him finding it difficulty to get up from bed, they tried to make him sit with support but he wasn't able to. He also has been having distended abdomen since 5 days and has not been able to pass stools since then. Since the past 3 days, they say that their father has not been able to talk
He has been in altered sensorium since the past 1 day
He hasn't been passing urine since 1 day
PAST HISTORY:- 2 years back: he experienced giddiness after which he visited a local hospital and was diagnosed with hypertension for which he has been using regular medications.
. 24 years back he got operated for ?colorectal carcinoma and was on medications for 2 years.
N/k/c/o DM,TB,Bronchial asthma,epilepsy
PERSONAL HISTORY:-he takes mixed diet and has normal
Apetite.History of constipation since 5days and no urine output since 1day
Occasional alcoholic since 40yrs
FAMILY HISTORY:-no similar complaints in family members
GENERAL EXAMINATION
On presentation:
Patient is conscious, responding when calls with inappropriate sounds
GCS - E4 V2 M5
VITALS:-
Afebrile
PR -100bpm RR:14cpm
Bp - 110/70mmhg
GRBS- 156mg/dl
Spo2 - 90 % on RA
Pupils were bilaterally constricted, reacting to light
Wincing to touch
CNS EXAMINATION:-
Neck stiffness +
Unable to perform kernigs as patient is not allowing to examine
Reflexes Right Left
UL B 3 + 3+
T 3+ 3+
S 2+ 2+
LL K + +
A + +
Plantar flexion bilaterally
Cranial nerves intact
PER ABDOMEN:-distented abdomen
Diffuse tenderness +
Bowel sounds +
CVS EXAMINATION:- S1, S2 heard .No murmurs
RESPIRATORY SYSTEM- Normal vesicular breath sound heard
INVESTIGATIONS:-
ECG
X-RAY CHEST PA VIEW:-
X-RAY ERECT ABDOMEN:-
HEMOGRAM:-
Hb:-9.4g/dl
TLC:-18,600
RBC:-3.59million
Platelets:-1,20,000
N:-90 L:-07 M:-02 E:-01
PCV:- 28 MCV:-78 MCH:-26.2 MCHC:-33.6
RFT:-
Urea:-101
Creatinine:-2.0
Uric acid:-7.0
Calcium:-9.6
Phosphate:-4.3
Sodium:-140
Potassium:-4.7
Chloride:-106
LFT:-
Total bilirubin:-1.31
Direct bilirubin:-0.83
AST:-297
ALT:-142
ALP:-215
Total protein:-4.9
Albumin:-2.9
Albumin/globulin:-1.09
D-Dimer:-550ng/ml
COMPLETE URINE EXAMINATION:-
Colour:-pale yellow
Appearance clear
Reaction acidic
Specific gravity:-1.010
Albumin:-+++
Sugar:-nil
Bile salts,bile pigments:-nil
Pus cells:-4-5
Epithelial cells:-2-4
RBC:-2-3
Crystals:-nil
Casts:-nil
Amorphous deposits:-absent
HBsAg:- negative
Anti-HCV antibodies :-non reactive
USG ABDOMEN:-
Distended gall bldder
Right kidney showed Grade1-grade1 RPD changes
Left kidney not visulaised in renal fossa
TROPONIN -I :-Negative
MRI BRAIN:-
2D ECHO
RWMA+ ;mild hypokinesia; concentric LVH+
Mild to moderate TR with PAH
Mild AR ; trivial MR
Sclerotic AV
No AS/MS
EF=55 RVSP=50mmHg
Diastolic dysfunction
IVC SIZE:-1.58cm(mild dilated)
PLAIN CT ABDOMEN
SARS COV-2 QUALITATIVE PCR:-positive
DIAGNOSIS:-
COVID PNEUMONIA
? SEPTIC ENCEPHALITIS/ ? MENINGITIS
? ISCHAEMIC HEART DISEASE
AKI ON CKD
KNOWN CASE OF HYPERTENSION SINCE 2 YEARS
TREATMENT GIVEN:-19/7/21 and 20/7/21
1.Head end elevation
2.IV FLUIDS -2NS continuous
1RL infusion @100ml/IV
3.D1 INJ.MONOCEF 1g IV/BD
4.RT FEEDS -100ml milk with 2scoops protien powder 2nd hrly 50ml free water hrly
5.INJ.PANTOP 40mg IV/OD
6.INJ.OPTINEURON 1amp in 100ml NS/IV/OD
7.Tab.DOLO 650mg PO/SOS
Yesterday(20/7/21) at 4:30PM patient was confirmed COVID POSITIVE BY RTPCR
And was referred to higher centre
29/7/21:- FOLLOW UP IN VIEW OF REFERRAL TO HIGHER CENTEE:-patient tested positive to COVID-19 and was taken to govt hospital
Got admitted for 4 days and expired yesterday(28/7/21)
DISCHARGE SUMMARY:-
90 year old man,resident of chittaluru, who used to work as a farmer 20years back presented to the casualty with the complaints of
High grade fever since 1 week
Unable to sit since 1 week
Unable to walk since 1 week
Abdominal distension since 5 days
Unable to pass stools since 5 days
Unable to speak since 3 days
Reduced urine output since 1 day
Altered sensorium since 1 day
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 1week ago
Then he had high grade,intermittent fever associated with chills and generalised weakness.He was unable to sit and walk since then.He was unable to pass stools since 5days and There was abdomen distension since 5days. 1 week back the patient's sons found him finding it difficulty to get up from bed, they tried to make him sit with support but he wasn't able to. He also has been having distended abdomen since 5 days and has not been able to pass stools since then. Since the past 3 days, they say that their father has not been able to talk
He has been in altered sensorium since the past 1 day
He hasn't been passing urine since 1 day
PAST HISTORY:- 2 years back: he experienced giddiness after which he visited a local hospital and was diagnosed with hypertension for which he has been using regular medications.
. 24 years back he got operated for ?colorectal carcinoma and was on medications for 2 years.
N/k/c/o DM,TB,Bronchial asthma,epilepsy
PERSONAL HISTORY:-he takes mixed diet and has normal
Apetite.History of constipation since 5days and no urine output since 1day
Occasional alcoholic since 40yrs
FAMILY HISTORY:-no similar complaints in family members
GENERAL EXAMINATION
On presentation:
Patient is conscious, responding when calls with inappropriate sounds
GCS - E4 V2 M5
VITALS:-
Afebrile
PR -100bpm RR:14cpm
Bp - 110/70mmhg
GRBS- 156mg/dl
Spo2 - 90 % on RA
Pupils were bilaterally constricted, reacting to light
Wincing to touch
CNS EXAMINATION:-
Neck stiffness +
Unable to perform kernigs as patient is not allowing to examine
Reflexes Right Left
UL B 3 + 3+
T 3+ 3+
S 2+ 2+
LL K + +
A + +
Plantar flexion bilaterally
Cranial nerves intact
PER ABDOMEN:-distented abdomen
Diffuse tenderness +
Bowel sounds +
CVS EXAMINATION:- S1, S2 heard .No murmurs
RESPIRATORY SYSTEM- Normal vesicular breath sound heard
TREATMENT GIVEN :- 19/7/21 and 20/7/21
1.Head end elevation
2.IV FLUIDS -2NS continuous
1RL infusion @100ml/hr
3.D1 INJ.MONOCEF 1g IV/BD
4.RT FEEDS -100ml milk with 2scoops protien powder 2nd hrly 50ml free water hrly
5.INJ.PANTOP 40mg IV/OD
6.INJ.OPTINEURON 1amp in 100ml NS/IV/OD
7.Tab.DOLO 650mg PO/SOS
ADVICE AT DISCHARGE:-
1.Rt feeds 100ml milk with 2 scoops of protein powder 2nd hourly and 50ml free water hourly
2. Tab Monocef 200mg/PO/BD for 7 days
3.Tab Pantop 40mg/PO/BBF for 7 days
4.Tab dolo 650mg sos
5. Tab Limcee 500mg /PO/OD
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