case 11 : 26M Altered Sensoriumand seizures

 

A CASE OF B/L PEDAL EDEMA, ALTERED SENSORIUM AND DYSPNEA.

July 26, 2021

 92 Sneha Nadipi

3rd Semester

Under the guidance of Dr.Pavan Kalyan(intern).

This is 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 patients clinical problems with collective current best evidence based inputs.

🖌This is an ongoing case. This blog post will be updated regularly.

A  26 year old male, driver by occupation presented with the 

   

*️⃣CASE SENERIO:

🌡CHIEF COMPLAINTS:

📌Dyspnea on exertion since 5 days and dyspnea on rest since 2 days

📌Yellowish discoloration of eyes since 5 days

📌Vomiting since 5 days .

📌B/L pedal edema since 3 days.

📌Fever since 2 days .

📌Decreased urine output since 2 days.

📌Unable to pass stools since 2 days and hematuria since 2days.

📌 He had 10-12 episodes of vomitings with food as content non-bilious since  4 days.

📌 Non blood tinged and  developed bilateral pedal edema up to knees.

📌 He received  Inj Ceftriaxone, IV fluids, Syrup Hepamerz in the outside hospital.

📌  He later started experiencing high grade, continuous fever since the last 2 days along with decreased urine output.

📌 unable to pass stools.

📌 Because of financial issues they got discharged from that hospital and presented to our casualty at 7PM on 25/7/21

📌Altered sensorium since 1 hour before coming to hospital.

🌡 TREATMENT HISTORY :

   

     No significant  history 

🌡️PERSONAL HISTORY : 

-  Married 

- Occupation : Driver

- Apettite loss:No

- Bowels : irregular

- Micturition : Decresed

- No H/O known drug allergies

-Alcohol : regular (7 years)

-Tobacco -Yes

🌡PHYSICAL EXAMINATION : 

A) GENERAL EXAMINATION :

 - Pallor- NO 

- lcterus-YES

- Cyanosis-No.  

- Clubbing of fingers/toes- No

- Lymphadenopathy-No

-Oedema of  feet- YES(B/L PEDAL EDEMA)

-Pupils-B/L pupils dilated

- Malnutrition - No

-Dehydration -NO 

- No H/O pallor, cyanosis , lymphadenopathy , clubbing of fingers or toes , dehydration

- Temperature : Afebrile 

- BP : 70\50 mmHg 

- PR : 49 BPM

- SPO2 : 85% at room air 

-GRBS:135 m/dl

-RR-36 cpm

🌡SYSTEMIC EXAMINATION:

B) CVS 

- Thrills : No 

- Cardiac sounds - S1 , S2 heard 

- Cardiac murmurs : No 

C) RS 

- Dyspnea : YES

- Wheeze : No 

-Inspiratory crepts-B/L IAA

D) ABDOMEN 

- Bowel sounds : YES 

E) CNS 

- altered sensorium

★ REFLEXES 

-Absent 

INVESTIGATIONS:

ECG:

X-RAY:

🌡SEROLOGICAL INVESTIGATIONS: ON 25/07/21(OUTSIDE)

Hb-13.8

TLC-14,100

PLT(plateletcount)-51,000

Serum creatinine: 3.7 mg/ dl

Blood urea: 128 mg/ dl

Sodium : 133 mEq/L

potassium : 3.6 mEq/L

chloride : 53 mEq/L

Liver Function Test:

TB   -19

DB   -7.8

IB-11.2

AST -147

ALT  -185

Alkaline Phosphate-135

TP:6.9

Alb-3.7

A/G-1.1 

Electrolytes:

Na-155 mmol/lit

K-5.4 mmol/lit

Cl-95 mmol/lit

Blood Glucose Test-Positive

S.lyase -102

PT-29 sec

INR-2.8

APTT-50 sec

Dengue-NEGATIVE 

HIV-NEGATIVE 

HCV-NEGATIVE 

HBS Ag-NEGATIVE 

ON 25/7/21(In Hospital)

Hb-13.9

TLC-16,950

PLT(plateletcount)-63,000

Serum creatinine: 2.7 mg/ dl

Blood urea: 89mg/ dl

Sodium : 133 mEq/L

potassium : 3.6 mEq/L

chloride : 53 mEq/L

Liver Function Test:

TB   -12.1

DB   -2.2

IB-11.2

Utica acid:6.2

AST -680

ALT  -140

Alkaline Phosphate-135

TP:5.2

Electrolytes:

Na-120 mmol/lit

K-5.1 mmol/lit

Cl-80 mmol/lit

ABG

pH:7.06

pCO2:18.4 mmHg 

pO2-not mentioned 

HCO3-7.9 mEq/mol

S.lyase -43

S.Amylase-82

BT:2 min 30 seconds 

CT:5 mins

PT-28sec

INR-2.0

APTT-57 sec

26/7/21:

  Over night BP monitoring chart:

ABG Report:

At 3AM:

Hemogram:

29/7/21

ABG Report:

Liver Function Test:

PROVISIONAL DIAGNOSIS:

Hepatic encephalopathy with acute decompensated liver failure

Hypotension secondary to ? Sepsis 

Right heart failure

Treatment:25/7/21

1. IVF-30 NS 
2. Inj.THIAMINE 1 amp in 100 ml IV/ID
3. Inj. VIT K IV/in 100 ml NS -DD
4. Plan for FFP transfusions 
5. TAB.Udiliv 300 mg po/TID
6. Syp . Lactulose 15 ml /po/TID
7. Syp.  Hepamerz 10 ml/po/BD
8. Inj. PIPTAZ  4.5 gm/IV—2.25 gm/IV/TID
9. Inj.methyl prednisole 40mg/IV/OD in 100ml NS
10. Propped up posture/head end elevation
11. TAB.RIFAGUT 500 mg BD/RT
12. Inj. PAN 40mg IV/OD
13. Oxygen supplementation maintains sPO2>95%
14. Monitor vitals-BP hourly 
15. Strict I/O charting
16. Inj. Noradrenaline 12ml/hour infusion
17. GRRS charting 6th hourly
18. Inj.Vasopressin infusion 2.4 ml/hour
19. Inj.LASIX 20mg IV/BD 8 AM - 4PM  IF SBP >110 mmHg
20. ABG every 6th hourly.