01/06/2023 : 55 year old female came with pain in abdomen from 10 days , altered sensorium since 1 week
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DOA - 29/05/2023
A 55 year old female who is a housewife resident of miryalaguda was brought to the OPD by her daughter with
CHIEF COMPLAINTS : Pain in abdomen from 10 days , altered sensorium since 1 week
HOPI : Patient was apparently asymptomatic 3 years ago
● On 1st january 2020 she developed fever which was continuous not associated with chills and rigours , relieved on medication
● She also had chest pain with burning sensation aggregated on work and relieved on rest
● She went to a hospital after 4 - 5 days of fever and chest pain . After investigations they found that one kidney has been failed
● On April 2022 She developed fever with chills and rigours which was insidious in onset, gradually proggresive ,continuous, No evening rise of temperature and also urine was whitish in colour.
● She went to hospital and was cured on medication
● From past 10 days she has pain in her abdomen (She had a huge intake of toddy 2 - 3 lit per day since one week before the occurrence of pain due to some festival )
● From the next morning she has fever which was insidious in onset, gradually proggresive, continuous with no chills and rigours, No evening rise of temp, sweating , generalised weakness with decreased food intake.
● 3-4 days later she started to have blurred / cloudy vision . So they went to a private hospital. On examining the patient they found her both kidneys had failed and suggested to perform dialysis.
● They were referred to government Nalgonda but she wasn't admitted and went to another hospital
● She was then unable to walk herself and loss of sensorium occurred . Sugar levels were raised.
● For dialysis she was referred to KIMS , Narketpally . She lost her recognition and was seen performing abnormal movements of hands and legs.
● Two sessions of dialysis were done on 28th and 30th of may 2023.
PAST HISTORY :
K/c/o HTN and DM since 18 years( Not on any medication )
Not a k/c/o TB, Asthma, Epilepsy, CAD
No Chemo/Radiation Exposure
No Surgical history
FAMILY HISTORY :
Mother is a k/c/o DM, Asthma
PERSONEL HISTORY :
Diet - Mixed
Appetite - Decreased since 10 days
Bowel movements - irregular ( last episode 1 week ago )
Allergies - No
Addictions - Toddy consumption 15-20 days once
Social history :
She was a fruit seller 6-7 years ago
She discontinued it as she go fever and weakness at that time
Currently she is a homemaker
Menstrual history : Menopause = At 40 years of age
TREATMENT History : Nil
GENERAL EXAMINATION :
Patient is conscious, coherent, not cooperative, loss of orientation.
Temperature - 99°F
Pulse - 103 beats/min
BP - 140/80 mmHg
RR - 23 cycles/min
GRBS - High
SPO2 - 95 %
No Pallor ,Icterus ,Clubbing ,Cyanosis, Lymphadenopathy
SYSTEMIC EXAMINATION :
CVS :
Inspection - Chest wall is symmetrical
No engorged veins ,scars, sinuses, pulsations.
Palpation - Apical pulse is at 5th intercostal space
Auscultation -
S1 , S2 are heard
No thrills and murmurs.
RESPIRATORY SYSTEM :
Inspection - Chest is Symmetrical
Trachea is central
Movements with respiration is equal on both sides
No dropping of shoulders, pectus excavatum/carinatum, dilated sinuses, scars.
Palpation -
Trachea is in midline
No crowding of ribs, intercostal tenderness
Percussion - Resonant in all areas
Auscultation -
Normal vesicular breath sounds
No wheeze, crackles etc
ABDOMEN :
INSPECTION -
Shape of abdomen - Obese
Umbilicus - Inverted
No scars, Sinuses, engorged veins
PALPATION -
No tenderness, Local rise of temp
Liver, Spleen not palpable
No palpable mass
PERCUSSION - Tympanic note
AUSCULTATION -
Bowel sounds heard
CNS EXAMINATION:
Patient is drowsy
Speech is normal , sometimes no response
Motor , Sensory , Cranial nerves examination is normal
Glasgow Scale - E2V2M4
INVESTIGATIONS :
BLOOD GROUP - A+ve
URINE FOR KETONES -ve
APTT - 34 sec
Prothrombin time - 17 sec
Serum iron 50.5 ug/dl
Blood lactate - 23.5 mg/dl
Random blood sugar - 486 mg/dl
Haemogram-
USG -
Consent taken -
PROVISIONAL DIAGNOSIS :
UROSEPSIS WITH AKI ON CKD WITH TYPE 2 RESPIRATORY FAILURE AND UNCONTROLLED SUGARS
TREATMENT :
IVF @ 50ml/hr
Inj PIPTAZ 2.25 GM IV/TID
Inj LASIX 40 mg IV/BD
Tab NODOSIS 500mg RT/BD
Tab SHELCAL 500mg RT/OD
Tab ECOSPRIN
RT feeds 100ml milk 4rth hourly
-100 ml water 2nd hourly
Monitoring vitals hourly
PATIENT WAS DISCHARGED ON LAMA ON 1/06/23 evening as the attenders want to go to a nearby govt hospital
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