80/M PTB CAP AKI RHF HTN

 80/M CAME TO CASUALITY 9-10-22 WITH 

CHEIF COMPLAINTS:

Fever since 10 days 

Decreased appetite since 10 days

Burning micturition since 1 day

Left loin pain since 1 day 

Decreased urine output since 1day

Blood in urine since 3 hrs


HISTORY OF PRESENTING ILLNESS

A 80Yr male, agriculture by occupation,clinically presented to casualty with complaints of high grade fever since 10 days (25th sep - 5th oct) , not associated with cold / cough/abdominal pain.which was releived on taking antipyretics and oral antibiotics . Afterday10 of illness his fever subsided . After 3 days i.e he had symptoms of burning micturition, abdominal distention and left loin pain , non radiating, dragging type and decreased urine output having dark yellowish coloured urine since 1 day. 




PAST HISTORY:

K/c/o : Hypertension since 1yr and taking medications irregularly 

Right lower end of tibial fracture 1 yr ago got operated

Not a K/c/o TB/asthma/CAD/CVD/epilepsy/ thyroid disorders


PERSONAL HISTORY:

80Yr male, married , agriculture by occupation, has normal appetite, mixed diet , regular bowels( not passed stools today), decreased urine output,no allergies, occasionally drinks ( once in a week) I.e (3.6 units of alcohol/week)

Smokes 10beedi/day (30 pack years)


No significant Family history


ON GENERAL PHYSICAL EXAMINATION 

Patient was drowsy , incoherent

GCS - E2( eye opening to pain)

            V2( verbal response- volcalises i.e  makes sounds but no word)

             M3( motor response I.e abnormal flexion to pain)

pallor present 

No icterus , cyanosis , clubbing, lymphadenopathy,edema


VITALS:  

On presentation 

Temp.-99.7

Bp- 120/90mmhg

PR-98bpm

RR-18cpm

Grbs-116mg/dl


  












SYSTEMIC EXAMINATIONS 

CVS: S1s2 heard

R/S : BAE+ , 

right infraxillary area crepts +

decreased breath sounds, 

P/A :scaphoid ,soft ,tenderness at umbilicus ,bowel sounds heard, stools passed yesterday 

















COURSE IN HOSPITAL 

A 80Yr male came to casualty with above mentioned complaints. Upon arrival initial assessment was done. He was started on intravenous fluid therapy. Urine analysis and culture and sensitivity were sent . 

febrile to touch 

GCS : E4V5M6

PR:142bpm

Bp:110/70mmhg

RR:18cpm

Pleural tap was done on 15/10/22


X-ray after pleural tap








TREATMENT:

1.IVF 3% NS @ 75ml/hr

2.INJ.MEROPENEM 500mg /IV /Bd for7 days

3. INJ.PAN40mg /iv/bd

4.inj. Tramadol 1Amp in 100ml Ns/iv/od

5.inj. NEOMOL 1gm 

6. Tab.dolo 650 mg/po/TID

7. Ryles  tube insertion 

8. Tab.  Azithromycin 500mg /po/od for 6 days

9. Inj. Vancomycin 1gm /iv/bd for 4 days

1st,3rd

2nd,4th 


X-ray on 16/10/22


Chest X-ray PA VIEW SUPINE POSITION TAKEN ON 17/10/22




Pleural fluid(EXUDATE)




Pleural fluid analysis- EXUDATE





Day 8

2nd time Pleural tap was done on 18/10/22



X-ray after pleural tap(2nd)

   
Patient developed pneumothorax 
Then after taking consent an ICD is placed in 5th ICS in mid axillary line



Fluid collected through ICD

( transudate)







Pleural fluid analysis:

Transudate






USG abdomen was done on 18/10/22




Ascitic Tap (diagnostic)was done on18/10/22
And sent for cytology, culture sensitivity, cell count





Day :9


S :  PAIN at site of ICD insertion, fever spike -yesterday 8pm 


O:

Pt c/c/c 

Bp - 110/70mmhg

PR - 110bpm

RR- 22cpm

Temp-98F

Spo2 - 92 at room air

CVS: S1S2+ loud s1@ aortic  and pulmonary area

apex beat at left 5th intercoastal space extended lateral to MCL

RS: BAE+

Inspection: Respiratory movements slightly more on right compared to left chest 

Crowding of ribs present

ICD- @ 5th Intercostal space @ mid axillary  line

 CREPTS AT 

LEFT INFRAAXILLARY AREA, IMA,ISA

RIGHT ISA,IMA


P/A: SOFT,BS+,Tenderness on palpation around umbilicus , stools not passed-D1

CNS: HMF INTACT 

          NO FND 

Input : 2300ml

Output: 1200ml








DIAGNOSIS:


ALTERED SENSORIUM SECONDARY TO ?HYPONATREMIA (resolved)- 

WITH CAP (RIGHT UL ANT LEFT LUNG)

? SEPTIC ENCEPHALOPATHY -LEFT PYELONEPHRITIS ( resolving)

WITH PRE RENAL AKI

with MICROCYTIC HYPOCROMIC ANEMIA SECONDARY TO  ?IRON DEFICIENCY 

? ANEMIA OF CHRONIC DISEASE 

WITH LEFT EMPYEMA 

WITH PNEUMOTHORAX WITH ICD DAY1

with k/c/o COPD and HTN 


 Treatment 


1)ALLOW ORAL FEEDS

2)IVF -NS/RL  @50ml/hr 

3) TAB. MIRTRAZAPINE 7.5mg/PO/HS

4)INJ. MEROPENEM 500 MG IV/BD (D10)

5) INJ. PAN 40MG IV/OD

6) INJ. TRAMADOL 1 AMP IN 100ML NS/IV/OD

7) INJ. VANCOMYCIN 1Gm/IV/BD(D7)

8) TAB. DOLO 650MG PO/ TID If temp.> 100F

9) NEB WITH DUOLIN 6th HOURLY and BUDECORT 8tH HOURLY 

10)VITAL + I/O CHARTING HOURLY 

11)ICD care 

bag always below waist 

Cap always open 

Check air coloum movement 

Maintain under water seal 

12)O2 inhalation with 2-4 lit

  1. Syp . POTCLOR 10ml in glass of water.

20/10/22 
ICU BED NO.6!
Day :11

S :  abdominal pain

O:
Pt c/c/c 
Bp - 120/70mmhg
PR - 112bpm
RR- 23cpm
Temp-100F
Spo2 - 90at room air ; 97% with 2lit O2
CVS: S1S2+ loud s1@ aortic  and pulmonary area
apex beat at left 5th intercoastal space extended lateral to MCL
RS: BAE+
Inspection: Respiratory movements slightly more on right compared to left chest 
 Auscultation:CREPTS AT 
LEFT INFRAAXILLARY AREA, IMA,ISA
RIGHT ISA,IAA

P/A: scaphoid , SOFT,BS+,Tenderness ++ diffuse 
CNS: HMF INTACT 
          NO FND 
Input : 1175ml 
Output: 990ml


A
ALTERED SENSORIUM SECONDARY TO ?HYPONATREMIA (resolved)- 
WITH CAP (RIGHT UL ANT LEFT LUNG) SECONDARY TO KLEBSIELLA PNEUMONIA
SPONTANEOUS BACTERIAL PERITONITIS -LEFT PYELONEPHRITIS WITH PRE RENAL AKI ( resolving)
WITH RIGHT HEART FAILURE SECONDARY TO CORPULMONALE
with MICROCYTIC HYPOCROMIC ANEMIA SECONDARY TO  ?IRON DEFICIENCY 
? ANEMIA OF CHRONIC DISEASE 
WITH LEFT EMPYEMA 
WITH PNEUMOTHORAX WITH ICD DAY3
with k/c/o COPD and HTN 

 


P
*
INJ. COLISTNMETHATE SODIUM 4.5 MIU./  Iv/OD/OVER 30MIN in100ML NS (DAY3)

Ambulization , wheel chair mobilization


21/10/22

21/10/22 
AMC BED NO. I
Day :12

S :  Diffuse abdominal pain

O:
Pt c/c/c 
Bp - 110/70mmhg
PR - 21bpm
RR- 21cpm
Temp-98.7F
Spo2 - 97at room air 
CVS: S1S2+ loud s1@ aortic  and pulmonary area
apex beat at left 5th intercoastal space extended lateral to MCL
RS: BAE+
Inspection: Respiratory movements slightly more on right compared to left chest 
On percussion: left4th,5th ICS - dull
 Auscultation:decreased breath sounds at IMA,ISA
CREPTS AT 
LEFT INFRAAXILLARY AREA, IMA,ISA
RIGHT IAA

P/A: scaphoid , SOFT,BS+,Tenderness + bowel sounds sluggish 
CNS: HMF INTACT 
          NO FND 
Input : 975ml
Output: 1200ml


A
ALTERED SENSORIUM SECONDARY TO ?HYPONATREMIA (resolved)- 
WITH CAP (RIGHT UL ANT LEFT LUNG) SECONDARY TO KLEBSIELLA PNEUMONIA
SPONTANEOUS BACTERIAL PERITONITIS  -LEFT HYDROURETERO NEHROSIS
 WITH PRE RENAL AKI ( resolving)
WITH RIGHT HEART FAILURE SECONDARY TO CORPULMONALE
with MICROCYTIC HYPOCROMIC ANEMIA SECONDARY TO  ?IRON DEFICIENCY 
? ANEMIA OF CHRONIC DISEASE 
WITH LEFT EMPYEMA 
WITH PNEUMOTHORAX WITH ICD DAY4
WITH GRADE I BED SORE
with k/c/o COPD and HTN 

 


P
1. NBM TILL FURTHER ORDERS (I/v/o diffuse abdominal pain, bowel wall edema)
2)IVF -NS/RL  @50ml/hr 
3) PROTIEN X- powder 2 scoops + 100ml milk
4) BUSCOPAN 20MG/IM/SOS
5) INJ. PAN 40MG IV/OD
6) TAB. MITRAZAPINE 7.5Mg po/Hs
8) TAB. DOLO 650MG PO/ TID If temp.> 100F
9) NEB WITH DUOLIN 6th HOURLY and BUDECORT 8tH HOURLY 
10)VITAL + I/O CHARTING HOURLY 
11)ICD care 
bag always below waist 
Cap always open 
Check air coloum movement 
Maintain under water seal 
12)O2 inhalation with 2-4 lit
13. Ambulation, wheel chair mobilization

* . COLISTNMETHATE SODIUM 
CBNAAT showed Tuberculosis positive, sensitive to  rifampicin 




22/10/22 
AMC BED NO. 1 
Day :13
80/Male
S :  Decrease appetite 
       loose stools since Yesterday (5episodes)
O:
Pt c/c/c 
Bp - 110/70mmhg
PR - 124bpm
RR- 19cpm
Temp-101F
Spo2 - 96at room air 
CVS: S1S2+ loud s1@ aortic  and pulmonary area
apex beat at left 5th intercoastal space extended lateral to MCL
RS: BAE+
Inspection: Respiratory movements slightly more on right compared to left chest 
On percussion: left4th,5th ,6th ICS - dull
 Auscultation:decreased breath sounds at IMA,ISA
CREPTS AT 
LEFT INFRAAXILLARY AREA, IMA,ISA
RIGHT IAA CREPTS
P/A: scaphoid , SOFT,BS+,Tenderness + ,bowel sounds+
CNS: HMF INTACT 
          NO FND 
Input : 975ml
Output: 1200ml
A
ALTERED SENSORIUM SECONDARY TO ?HYPONATREMIA (resolved)- 
WITH CAP (RIGHT UL ANT LEFT LUNG) SECONDARY TO KLEBSIELLA PNEUMONIA
SPONTANEOUS BACTERIAL PERITONITIS  -LEFT HYDROURETERO NEHROSIS
 WITH NON OLIGURIC AKI
WITH RIGHT HEART FAILURE SECONDARY TO CORPULMONALE
with MICROCYTIC HYPOCROMIC ANEMIA SECONDARY TO  ?IRON DEFICIENCY 
? ANEMIA OF CHRONIC DISEASE 
WITH LEFT EMPYEMA 
WITH GRADE I BED SORE
PULMONARY TUBERCULOSIS 
with k/c/o COPD and HTN 



P
1. Allow oral fluids 2lit/day
2)IVF -NS/RL with optineuron  @50ml/hr 
3) Tab. SPOROLAC po/sos
4) BUSCOPAN 20MG/IM/SOS
5) INJ. PAN 40MG IV/OD
6) TAB. MITRAZAPINE 7.5Mg po/Hs
8) TAB. DOLO 650MG PO/ TID If temp.> 100F
9) NEB WITH DUOLIN 6th HOURLY and BUDECORT 8tH HOURLY 
10)VITAL + I/O CHARTING HOURLY 
12)O2 inhalation with 2-4 lit
13. Ambularono , wheel chair mobilization 
14. PROTIEN X- powder 2 scoops + 100ml milk 
15. ATT.—TAB. Isoniazide 215mg/po/od , 
16. Tab. RIFAMPICIN 430mg/po/od
17. Tab.pyrizinamide 1125mg/po/od
18. Tab.Ethambutol 540mg/po/od

25/10/22
Day :16
S : pruritis, no fever spike , Right hypochondriac pain
O:
Pt c/c/c 
Bp - 110/80mmhg
PR - 120pm
RR-24cpm
Spo2 - 96%at room air 
CVS: S1S2+ loud s1@ aortic  and pulmonary area
apex beat at left 5th intercoastal space extended lateral to MCL
Parasternal heave +
RS: BAE+
On percussion: less  resonant on left side
 Auscultation: BAE+ no abnormal sounds heard
P/A: scaphoid , SOFT,BS+,Tender right hypocondrium ,4episodes of stools
CNS: HMF INTACT 
          NO FND 
Input : 2900ml
Output: 2050ml
A
PULMONARY TUBERCULOSIS on ATT( Started on 22/10/22)
Left CAP secondary to klebsiella pneumonia with left pneumothorax (resolved)
With left hydrouretronephrosis
With non oliguric AKI
With culture negative neutrocytic ascitis 
With right heart failure secondary to 
Cor-Pulmonale
With COPD with Hyponatremia (resolved)
With k/c/o HTN with grade 1 bed sore

P
1. Allow oral fluids 2lit/day
2.IVF -NS/RL  @50ml/hr 
3.BUSCOPAN 20MG/IM/SOS
4.INJ. PAN 40MG IV/OD
5.TAB. MITRAZAPINE 7.5Mg po/Hs
6.TAB. DOLO 650MG PO/ TID If temp.> 100F
7.NEB WITH DUOLIN 6th HOURLY and BUDECORT 8tH HOURLY 
8.VITAL + I/O CHARTING HOURLY 
9.cap. Kedotil 100mg/po/sos(if loose stools+)
10. Ambulation,wheel chair mobilization 
11.PROTIEN X- powder 2 scoops + 100ml milk 12.ATT.(day4)
TAB. Isoniazide 300mg/po/od , 
Tab. RIFAMPICIN 450mg /po/od
13.Tab. Benadone 40mg/po/od
14.Inj.Zofer 4mg /iv/sos


25/10/22 
Day :16
S : pruritis, no fever spike , Right hypochondriac pain
O:
Pt c/c/c 
Bp - 110/80mmhg
PR - 120pm
RR-24cpm
Spo2 - 96%at room air 
CVS: S1S2+ loud s1@ aortic  and pulmonary area
apex beat at left 5th intercoastal space extended lateral to MCL
Parasternal heave +
RS: BAE+
On percussion: less  resonant on left side
 Auscultation: BAE+ no abnormal sounds heard
P/A: scaphoid , SOFT,BS+,Tender right hypocondrium ,4episodes of stools
CNS: HMF INTACT 
          NO FND 
Input : 2900ml
Output: 2050ml
A
PULMONARY TUBERCULOSIS on ATT( Started on 22/10/22)
Left CAP secondary to klebsiella pneumonia with left pneumothorax (resolved)
With left hydrouretronephrosis
With non oliguric AKI
With culture negative neutrocytic ascitis 
With right heart failure secondary to 
Cor-Pulmonale
With COPD with Hyponatremia (resolved)
With k/c/o HTN with grade 1 bed sore

P
1. Allow oral fluids 2lit/day
2.IVF -NS/RL  @50ml/hr 
3.BUSCOPAN 20MG/IM/SOS
4.INJ. PAN 40MG IV/OD
5.TAB. MITRAZAPINE 7.5Mg po/Hs
6.TAB. DOLO 650MG PO/ TID If temp.> 100F
7.NEB WITH DUOLIN 6th HOURLY and BUDECORT 8tH HOURLY 
8.VITAL + I/O CHARTING HOURLY 
9.cap. Kedotil 100mg/po/sos(if loose stools+)
10. Ambulation,wheel chair mobilization 
11.PROTIEN X- powder 2 scoops + 100ml milk 12.ATT.(day4)
TAB. Isoniazide 300mg/po/od , 
Tab. RIFAMPICIN 450mg /po/od
13.Tab. Benadone 40mg/po/od
14.Inj.Zofer 4mg /iv/sos

https://nehareddygaddam.blogspot.com/2022/10/80yr-male-with-altered-sensorium.html




26/10/22 

Day :17

S : pruritis, no fever spike , Right hypochondriac pain, loose stools(?antibiotic induced?)

O:

Pt c/c/c 

Bp - 110/60mmhg

PR - 136pm

RR-26cpm

Spo2 - 97%at room air 

CVS: S1S2+ loud s1@ aortic  and pulmonary area

apex beat at left 5th intercoastal space extended lateral to MCL

Parasternal heave +

RS: BAE+




On percussion: less  resonant on left side

 Auscultation: BAE+ no abnormal sounds heard,decreased breath sounds in IAA,IMA

P/A: scaphoid , SOFT,BS+,Tender right hypocondrium ,episodes of loose stools

CNS: HMF INTACT 

          NO FND 

Input : 2500ml

Output: 2000ml

A

PULMONARY TUBERCULOSIS on ATT( Started on 22/10/22)

Left CAP secondary to 

klebsiella pneumonia superinfection 

with left pneumothorax (resolved)

With left hydrouretronephrosis

With non oliguric AKI

With culture negative neutrocytic ascitis 

With right heart failure secondary to 

Cor-Pulmonale

With COPD with Hyponatremia (resolved)

With k/c/o HTN with grade 1 bed sore


P

  1. Allow oral fluids 2lit/day

3.BUSCOPAN 20MG/IM/SOS

4.INJ. PAN 40MG IV/OD

5.TAB. MITRAZAPINE 7.5Mg po/Hs

6.TAB. DOLO 650MG PO/ TID If temp.> 100F

7.NEB WITH DUOLIN 6th HOURLY and BUDECORT 8tH HOURLY 

8.VITAL + I/O CHARTING HOURLY 

9.cap. Kedotil 100mg/po/sos(if loose stools+)

  1. Ambulation,wheel chair mobilization 

11.PROTIEN X- powder 2 scoops + 100ml milk 12.ATT.(day5)

TAB. Isoniazide 300mg/po/od , 

Tab. RIFAMPICIN 450mg /po/od

TAB.Pyrazinamide 1500mg/po/odc

TAB. Ethambutol 400mg /po/od

13.Tab. Benadone 40mg/po/od

14.Inj.Zofer 4mg /iv/sos



PATIENT WAS DISCHARGED AND CONTINUED ATT WITH REGULAR FOLLOW UP IN GOVERNMENT HOSPITAL NALGONDA. 

ON 01-11-22 PATIENT COMPLAINED OF DIFFICULTY IN BREATHING AND WAS TAKEN TO OUTSIDE HOSPITAL WHERE HE WAS INTUBATED AND IS ON MECHANICAL VENTILATOR FOR 2 DAYS AND WAS DECLARED DEAD ON 03-11-22.

OUTCOME : MORTALITY

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