39 year old male patient with Altered sensorium and Paraplegia
A 39 year old male patient resident of Nalgonda, electrician by occupation was presented to the casualty on 9th of November,2021
As informed by his attenders
C/o decreased responsiveness, loss of appetite and decreased speech since 2 days before admission and completely couldn't talk on the day of admission.
History of presenting illness
Patient was apparently asymptomatic 8months ago then he developed pain abdomen and intermittent low back pain and dribbling of urine so he visited a physician and was told to have renal stones and meatal stenosis for which he underwent urethral dilatation in July, 2021.
He was incidentally detected to have serum creatinine 5g/dL while visiting a hospital in Nalgonda. His urine output was good and he had no pedal edema or sob. He was told to have renal failure and was on medication since then.
He had h/o weight loss and loss of appetite and low grade fever.
He was having intermittent back pain since then
After 2 months, in the last week of August, 2021 he developed left lower limb weakness which gradually progressed to right lower limb resulting in paraplegia for which MRI lateral spine was done and was suspected to have Potts spine
He used ATT for 15 days and stopped due to nausea and loss of appetite. Patient was bed ridden since then and started using unnani medication neglecting the advised ATT medication.
Hemodialysis was advised 2 months ago but didn't get it done due to fear of hemodialysis as one of his relative passed away while undergoing hemodialysis.
Since September, 2021 he developed bed sores for which once daily dressing done but patient was active and talked to everyone.
Since 10 days patient was complained to have low grade fever, nausea, shivering with no h/o loose stools, vomiting, head ache, blurred vision.
Since 1 day(as of admission day) patient was complained to have loss of appetite and was unable to speak(sudden in onset) but was able to obey commands.
On the day of admission,patient presented with Altered sensorium, not able to obey commands and involuntary movement of b/l lower limb (Right>Left).
Past History
Not a known case of DM, HTN, Epilepsy, Asthma, pulmonary TB.
Personal History
Diet - Mixed
Appetite - Decreased
Sleep - couldn't sleep at night since 1 month
Regular bowel movements. Was on Foley's since 6 months
Occasionally drinks Alcohol. Nonsmoker.
Family History
His parents passed away due to old age
He has 6 siblings of which one sister and his Maternal Aunt are suffering with CKD. Patient's Uncle passed away while undergoing treatment for CKD.
Medical History - None since childhood
Surgical History - None
General Physical Examination
Pallor present
No icterus, cyanosis, clubbing, edema , lymphadenopathy.
VITALS ON ADMISSION:-
Temp:- 101F
PR:- 92 BPM
RR:-14 cpm
BP: 90/60 mmHg
Spo2:- 83 % at RA
GRBS:- 195 MG%
Systemic Examination
CVS:- S1 S2+ ,NO MURMUR
RS:- BAE+ , NVBS+
P/A SOFT ,NT
CNS:- Eye opening to pain
No verbal response
No meningeal signs
GCS:- E2 V1 M5. 8/15
PUPILS - B/L mid dilated unequal(Right>Left)
Plantars - B/l Flexion
Power -. Rt Lt
Upper limb - 5/5. 5/5
Lower limb- plegia plegia (0/5)
Tone --
Upper limb- Increased Increased
Lower limb- Decreased Decreased.
Reflexes:- Right Left
Biceps- absent. 2+
Triceps- 3+. 3+
Wrist - 2+. 2+
Knee - Absent. Absent
Ankle - Absent. Absent.
Provisional Diagnosis
1. Altered Sensorium
2. CKD
3. Paraplegia secondary to Potts spine
4. Grade 4 bed sore
Flaccid paraplegia
Investigations:-
Hb:- 3.8
Platelets:- 61000
Blood group:- A Positive
Na-137
K-4.3
Cl-98
Sr.creat-4.2
LFT:-
TB- 0.92
DB-0.27
SGOT-18
SGPT-24
ALP-375
TP- 4.7
ALBUMIN:-2.0
A/G :-0.76
LDH:- 225
Blood urea- 247
Rbs-143
Serology - NEGATIVE
C-reactive protein-- POSITIVE-2.4 mg/dL
TREATMENT :-
1) IVF NS-2 units
RL-1 unit
Dns- 1 unit @ 100 ml/hr
2) Inj. Optineuron 1 amp in 100 ml NS IV OD
3) Inj. Levipil 1 gm IV stat--500 mg iv bd
4) RT Feeds milk + Protein powder 4th hourly..free water 200 ml 4th hourly
D1-5) Inj. Ceftriaxone 2gm iv bd
6) Inj. Neomol 1 gm IV SOS
7) Tab. Dolo 650 mg RT TID
8) Inj. Pantop 40 mg IV OD
9) ATT According to renal clearance and wt.
10) GRBS 12 TH HOURLY
I/O CHARTING
BP/PR MONITORING.
11) INJ. Pan 40 mg /Iv /Od
12) Inj. ZOFER 4 mg iv bd
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