55 M with Altered sensorium and right pleural effusion

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CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDER

Chief complaints:

Patient came with complaints of lower back ache since 3 weeks radiating to left lower limbs

History of presenting illness:

Patient was apparently asymptomatic 3 weeks back,then patient complained of lower back ache which is sudden onset, progressive ,aggravates on movement and relieves on rest.

H/o slip and fall from steps 3 weeks back and was taken to an outside hospital and found to have L5 burst fracture on CT pelvis and then he was brought here for further management. 

No h/o lifting heavy weights,fever,burning micturition, Bowel and bladder incontinence. 

Past history of right proximal femur fracture and underwent IMILN 10 years back.

H/o PTCA done one and half year back and is on regular medication 

K/c/o DM II since 20 years and is on T. Metformin 500 mg + T. Voglibose 0.2 mg + T. Glimiperide 2 mg

On General examination :

Patient is conscious and coherent.

No signs of pallor,icterus,cyanosis, clubbing, lymphadenopathy or edema

Vitals at presentation:

Afebrile 

BP: 110/60 mm Hg

PR : 80 bpm

RR : 18cpm 

Systemic examination:

CVS: S1,S2 heard

CNS: NFND

PA : Soft, non tender

RS : BLAE +

B/L of LS spine:

Skin- Normal

Swelling- absent

Tenderness- Present at lumbar region

Tracheostomy was done on 6/9/23

Blood transfusion was done on 12/9/23

Pulmonology referral was done on 30/8/23 and advised for CT Chest and induced sputum for CBNAAT and culture sensitivity.

Nephrology referral was done on 2/9/23 and advised for haemodialysis 

Pulmonology was referral done on 2/9/23 was advised for USG guided tap and ICD placement.

Surgery referral was done on 4/9/23 was advised for aseptic dressings for his bed sore.

Investigations:

29/8/23:

RFT:

Urea 77 mg/dl

Creatinine 1.1 mg/dl

Uric acid  2.9 mg/dl

Na 121 mEq/L

K 4.6 mEq/L

Ca 8.8 mg/dl

Cl 95 mEq/L

LFT:

TB 0.76 mg/dl

DB 0.19 mg/dl

AST 11 IU/L

ALT 13 IU/L

ALP 321 IU/L

ALB 2.59 gm/ dl

Hemogram:

Hb 9 gm /dl

TLC 15300 cells/cumm

PLC 1.8 L/cumm

N/L/E/M/B  87/10/1/2/0

CUE:

Albumin +

Sugar ++++

Pus cells 2-4

Epithelial cells 2-3

ABG:

pH 7.43

pCO2 27.6

pO2 48.1

HCO3 18.1

On 4/9/23:

LFT 

TB 1.63 mg/dl

DB  0.25 mg/dl

AST 27 IU/L

ALT 32 IU/L

ALP 399 IU/L

TP 4.5 gm/dl

ALB 1.86 gm/dl

RFT:

Urea 196 mg/dl

Creatinine 4.5 mg/dl

Uric acid  7.5 mg/dl

Na 133 mEq/L

K 4.4 mEq/L

Ca 8.2 mg/dl

Cl 97 mEq/L

Hemogram(5/9/23)

Hb 7 gm /dl

TLC 23600 cells/cumm

PLC 1.63 L/cumm

On 9/9/23

RFT:

Urea 29 mg/dl

Creatinine 4.5 mg/dl

Uric acid  1.1 mg/dl

Na 132 mEq/L

K 4.9 mEq/L

Cl 99 mEq/L

Hemogram(12/9/23)

Hb 6.5 gm /dl

TLC 20,500 cells/cumm

PLC 2.43 L/cumm

On 15/9/23:

RFT:

Urea 50 mg/dl

Creatinine 0.8 mg/dl

Uric acid 4.2 mg/dl

Na 133 mEq/L

K 3.8 mEq/L

Cl 99 mEq/L

Hemogram(15/9/23)

Hb 6.2 gm /dl

TLC 19,200 cells/cumm

PLC 1.5 L/cumm

2D echo:

Tachycardia,mild LVH

RWMA; Apex,Anterior wall and Lateral wall hypokinesia

Trivial MR/AR , no TR

Sclerotic AV, no AS/MS

EF: 44%, moderate LV dysfunction 

No diastolic dysfunction, no PAH/PE

HRCT CHEST:

Right lower lobe collapse with bronchiectasis

Foci of consolidation in Right middle lobe, lingula and apical segment of left lung lower lobe

Large loculated right pleural effusion extending into the major fissure.

A pocket of loculated mediastinal pleural effusion on Right side

Chronic calcific Pancreatitis 

USG Abdomen- No sonological abnormalities detected

Treatment given:

1. INJ. LEVIPIL 1gm IV/BD given for 16 days

2. INJ NORAD @1.1 ml/hr for 7 days

3. INJ DOBUTAMINE IV for 7 days

4. INJ VASOPRESSIN @5 ml/hr for 6 days

5. INJ FENTANYL + MIDAZOLAM IV for 8 days

6. INJ HEPARIN for 13 days

7. TAB. TOLVAPTAN for 6 days

8. INJ THIAMINE for 7 days

9. INJ HAI for 16 days

10. INJ PIPTAZ 2.25 gm IV TID for 5 days

11. TAB ATORVASTATIN + ASPIRIN 75 mg RT/HS  for 16 days

12. TAB. OROFER XT PO OD for 16 days

13. Nebulisation with IPRAVANT 6th hourly and BUDECORT 4th hourly for 16 days

14. INJ MEROPENEM 500 mg IV BD for 12 days

15. TAB. FLUCONAZOLE 150 mg RT OD for 8 days

16. INJ VANCOMYCIN 500 mg IV BD for 5 days

17. Change of position 2nd hourly and daily dressing of bed sore

COURSE IN THE HOSPITAL:

A 55 year old male with L5(unstable) burst fracture (3 weeks old ) and was transferred from orthopaedics to General medicine i/v/o high GRBS . Patient sugars were controlled with insulin infusion and handed over to orthopaedics. After 1 hr patient developed Altered sensorium and transferred to GM . Altered sensorium was thought to be due to hyponatremia was corrected with 3% NaCl.

Next day i/v/o falling saturation , patient was intubated. He also had bradycardia at that time and CPR was initiated and patient relieved. As breath sounds decreased on Right side of Chest ,HRCT CHEST was done .

Patient developed Heart Failure with 44% Ejection Fraction, D-dimer was found to be elevated initially , pulmonary embolism was suspected and HEPARIN was added to the treatment. Patient had hypotension and was put on inotrope support. As there were raised counts and fever spikes in between, antibiotics were started.

Patient had decreased urine output and increased Serum Urea and Serum Creatinine. Diuretics were added to the treatment and gradually urine output increased. He was maintained on Ventilator and triple inotrope support. His blood pressure improved gradually and gradually inotrope suport was weaned off. Patient had recurrent episodes of seizures in between and was controlled with antiepileptics. 

On 6/9/23, patient was tracheostomised and  maintained on Ventilator. 

Due to low Hb levels 1 PRBC transfusion was done on 12/9/23. 

Sepsis was resolving gradually and antibiotics were de escalated gradually.

Oxygen support was tapered and patient was maintaining on room air on 14/9/23.

On 16/9/23, at around 2 am patient was again connected to Oxygen support i/v/o falling saturation and maintained on it for 2 hours and around 5 am patient had falling saturation even with high flow oxygen support and had bradycardia. 

At around 5 am CPR was started and continued for 30 mins. Inspite of efforts, patient expired .