45Y/F WITH C/O GENERALISED WEAKNESS SINCE 2 DAYS

 CBBLE UDHC SIMILAR CASES

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 

45 years old P3L3 female, agricultural labourer by occupation, came to the casuality with C/O generalised weakness since 2 days.

H/O vomitings and loose stools 2 days back.

HOPI:

Patient was apparently asymptomatic 1 year back and then had H/O Neck pain and backache - dragging type of pain, not associated with any numbness, tingling sensation of upper and lower limbs.

Patient started taking NSAID daily once for pain for 1 month, then she visited orthopaedician and advised her to get MRI: L-Spine and after that she was advised for surgery.

Patient had difficulty in passing stools (constipation) since 1 month for which the patient went to the nearby doctor 2 days back.

She was put on Syp. Lactulose and after 1 day, the patient had 5 episodes of watery stools for 1 day, 2 episodes of vomitings for 1 day which subsided now.

Generalised weakness present since 2 days.

PAST HISTORY:

Not a K/C/O DM/HTN/BA/TB/Epilepsy/Thyroid disorders/CAD/CVA

Patient underwent ECSL for Right Renal stones (ECSL) 6 years back, Hysterectomy 20 yrs back and Left Cataract Surgery 6 yrs back.

PERSONAL HISTORY:

Diet- mixed

Appetite- Normal

Sleep- Adequate

Bowel and bladder movements- Regular

No known allergies

No addictions

Family history: not significant

GENERAL EXAMINATION:

Patient is Conscious, coherent, cooperative.

No Pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema.

Vitals:

Temp.- Afebrile

BP- 110/70 mmHg

PR- 100 bpm

RR- 12 cpm

SpO2- 98%

GRBS- 138 mg/dL

SYSTEMIC EXAMINATION:

CVS- S1 S2 heard, no murmurs

RS- BAE+ NVBS+

P/A- Soft, Non-tender

CNS- 

Patient is Lethargic

GCS- 15/15

Sensory and motor systems - Intact

Cranial nerves- intact

Reflexes- Intact

INVESTIGATIONS

USG ABDOMEN:

CHEST X-RAY PA VIEW:

X-RAY L-SPINE:

X-RAY L-SPINE Report :

C-Reactive protein: Positive on DOA:5 (2.4 mg/dL)

RFT on DAY 6

PROVISIONAL DIAGNOSIS:

AKI on CKD secondary to ?anagesic neuropathy

Pyrexia under evaluation

TREATMENT GIVEN:

1. IV Fluids NS and RL @ UO+50 ml/h

2. Inj. Optineuron 1 amp in 100 ml NS

3. Inj. PANTOP 40 mg IV OD

4. Inj. Lasix 20 mg IV BD (if sBP>110 mmHg)

5. Inj. Neomol 100 ml IV SOS (if temp>101 F)

6. Tab. PCM 500 mg PO SOS

7. GRBS - 6th hrly

8. I/O Charting

9. Monitor vitals 4th hrly

Orthopedics referral:

Nephrology Referral:

SOAP NOTES:

Day 2 

S: 

Generalised weakness present

No fresh complaints

O:

Temp.- Afebrile

BP- 120/70 mmHg

PR- 98 bpm

RR- 18 cpm

SpO2- 97% at RA

GRBS- 103 mg/dL

A:

Viral Pyrexia with Thrombocytopenia

AKI secondary to ?Sepsis

P:

1. IVF - NS,RL,DNS @ UO+100 ml/h

2. Inj. PANTOP 40 mg IV OD

3. Inj. Zofer 4 mg IV SOS

4. Inj. Lasix 40 mg IV BD (if sBP>110 mmHg)

5. Inj. Neomol 100 ml IV SOS (if temp>101 F)

6. Tab. PCM 500 mg PO/SOS

7. Tab. Doxycycline 100 mg PO/BD

8. Monitor vitals 4th hrly

9. I/O and Temp. Charting

Day 3

S:

C/o burning micturition, nausea (+), decreased appetite, 

No h/o fever, vomitings

O:

Pt is C/C/C

Temp- afebrile

Bp- 120/70 mmhg

PR- 74bpm

RR- 16cpm

SPO2- 99% 

CVS- S1 S2 heard

Rs- BAE+

CNS- NFND

P/A- Soft, Non-tender

A:

Viral pyrexia with thrombocytopenia

AKI secondary to ?GE 

With UTI secondary with R renal calculi

P:

1. IVF- NS RL DNS UO+ 50ml/hr

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

3. Inj. Pantop 40mg IV OD

4. Inj. Zofer 4mg IV OD

5. Inj. Neomol 1amp in 100ml NS IV if temp >101F

6. T. PCM 500mg PO/SOS

7. Temperature and I/O charting

8. Vitals monitoring

Day 4 

S:

C/o burning micturition, nausea (+) decreased appetite, 

No h/o fever, vomitings

O:

Pt is C/C/C

Temp- afebrile

Bp- 110/70 mmhg

PR- 72 bpm

RR- 17 cpm

SPO2- 98% 

CVS- S1 S2 heard

RS- BAE+

CNS- NFND

P/A- Soft, Non-tender

A:

Viral pyrexia with thrombocytopenia

AKI secondary to ?GE 

With UTI secondary with R renal calculi

P:

1. IVF- NS RL DNS UO+ 50ml/hr

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

3. Inj. Pantop 40mg IV OD

4. Inj. Zofer 4mg IV OD

5. Inj. Neomol 1amp in 100ml NS IV if temp >101F

6. T. PCM 500mg PO/SOS

7. Temperature and I/O charting

8. Vitals monitoring

Day 5 

S:

C/O decreased appetite and nausea+

No fever spikes

O:

Pt is C/C/C

Temp- Afebrile

Bp- 110/80 mmhg

PR- 82 bpm

RR- 18 cpm

SPO2- 99% 

CVS- S1 S2 heard

RS - BAE+

CNS- NFND

P/A- Soft, Non-tender

A:

Viral pyrexia with thrombocytopenia

AKI secondary to ?GE 

With UTI secondary with R renal calculi

P:

1. IVF- NS RL DNS UO+ 50ml/hr

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

3. Inj. Pantop 40mg IV OD

4. Inj. Zofer 4mg IV OD

5. Inj. Neomol 1amp in 100ml NS IV if temp >101F

6. Inj. Lasix 40 mg IV BD if sBP>110 mmHg

7. T. PCM 500mg PO/SOS

8. T. Doxycycline 100 mg PO/BD

9. Syp. Lactulose 15 ml PO/HS

10. Syp. Aristroxyme 15 ml PO/TID

11. Syp.Cremaffin 5ml PO/TID HS

12. Temperature and I/O charting

13. Vitals monitoring

14. GRBS monitoring 12 th hrly