A 52 YEAR OLD FEMALE WITH ALTERED SENSORIUM .
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CASE :
A 52 year old female who is homemaker by occupation , came to the casuality in a drowsy state.
she was appparently asymptomatic 15 days back then she had sudden onset of vomitings around 10 -15 episodes , then she is not responding to the talk and sudenly went into a drowsy state . she was being shifted to the hospital and admitted in the casuality .
According to the patient attender she had an episode of seizures in the hospital .
On presentation patient was unconscious with E1V1M4 to E1V1M1 .
PAST HISTORY :
No h/o Diabetes , hypertension, epilepsy, asthma, TB, thyroid disorders .
No similar complaints in the past .
History of hernia surgery in the past.
PERSONAL HISTORY :
Diet : Mixed
Sleep: adequate
Bowel and Bladder : Regular
Appetite : Decreased
No known allergies
No history of smoking and alcohol consumption .
ON EXAMINATION : ( 28/10/21)
Patient is stuporous , withdrawal from pain
Temperature : febrile , 100 F
PR : 124
BP : 120/80 mm hg
RR : 35 cpm
SPO2 : 98 % on 15 lt of O2
CVS : S1 , S2 heard
RS : BAE present ,inspiratory crepts (+)
SPO2 98% 0n 15 lt of O2
P/A : obese , non tender , bowel sounds are sluggish
CNS :
pupils - right side - NS RL
left side - post cataract surgery r/n to light
gag present
GCS - E2V1M4
Tone - Normal , B/L
Reflexes -
left right
B : 2+ 2+
T : 2+ 2+
S : 2+ 2+
K : 2+ 2+
A : 2+ 2+
plantaris : upgoing , upgoing
PROVISIONAL DIAGNOSIS :
Altered sensorium under evaluation secondary to
Hyponatremia ? SIADH
Sepsis secondary to ? Cellulitis ? Typhoid
With complete Right bundle branch block.
INVESTIGATIONS :
ECG :
MRI BRAIN :
TREATMENT :
* IVF 3% NACL @ 10 ml /hr till 1 pm
* INJ pantop 40 mg / IV /OD
* INJ piptaz 4.5 gm /IV / TID
* RT - 100ml milk
50ml water - 2 hourly
* Neb with BUDECORT - 8th hrly
ASTHALIN - 12th hrly
* Monitor vitals hrly
* Oral suction every hourly
ON 29/09/21 :
ON EXAMINATION -
pt is stuporous , eye opening on painful stimuli
E2V1M1
Febrile to touch
PR - 107/min
BP - 130/70 mm hg
CVS - S1 S2 HEARD
RS - BAE (+) , Decreased in right ISA
Grunting in all areas
CNS- DOLLS EYE (+)
Pupils - Rt -NS RL
Lt -post cataract surgery
TONE- decreased in all limbs
Plantaris B/L mute
P/A - obese , bowel sounds present
INVESTIGATIONS :
SERUM ELECTROLYTES :
UREA - 53
CREATININE - 1.3
URIC ACID - 4.8
CALCIUM - 8.0
Na + - 120
POTASSIUM - 3.6
CL - 80
URINARY ELECTROLYTES :
URINARY Na + - 239
K+ - 29.4
CL - 268
2D ECHO REPORT :
* TACHYCARDIA
* Concentric left ventricular hypertrophy ( 1.4 cms)
* Trivial AR + /TR+ , NO MR
* Sclerotic AV , No AS / MS
* EF = 54% , RVSP 35 mm hg
* Good to fair LV function
* Diastolic dysfunction , No PAH/PE
8 IVC size (1.15 cms)
TREATMENT :
* Propped up position 30 degrees
* Ryles catheterisation
* Air/Water Bed
* RT feeds - 50ml milk with protein powder -4th hourly
* INJ MEROPENEM 1gm /IV/ BD
* INJ DOXYCYCLINE 100mg /IV/ BD
*INJ FALCIGO 120mg/Iv /STAT
*INJ PANTOP40mg /IV/OD
* T. TOLVAPTAN 15mg /PO/OD
* ABG 6th HOURLY
* ORAL SUCTION 2 HOURLY
* FLUID RESTRICTION < 1LIT /DAY
*INJ CEFTRIAXONE 2 g /IV BD
* INJ DEXA 4mG /IV/ BD
ON 30/09/21 :
Altered sensorium under evaluation
secondary to hyponatremia - renal loss
with sepsis secondary to cellulitis With GRADE 2 BED SORES
WITH ischemic hepatitis
? meningoencephalitis
* Fever spikes (-)
* passed stools
ON EXAMINATION :
Patient on mechanical ventilator
Mode - SIMV volume control
FiO2 - 30%
NT -400ml
PEEP- 5cm 0f H20
TEMP : 37.3 C
BP : 110/60 mm hg
PR ; 94 /min
CVS- S1 , S2 heard
RS - BAE (+)
P/A - soft , non tender , bowel sounds present
CNS -
DOLLS EYE (+)
PUPILS - reacting to light
TONE -
Upper limb - decreased
Lower limb - decreased
PLANTARIS - B/L mute .
TREATMENT :
* PROPPED UP POSITION 30 DEGREES
* RYLES FEEDING - WITH 50ML MILK WITH PROTIEN POWDER 4th hrly
* INJ MEROPENEM 1gm /IV/BD
* INJ DOXYCYCLINE 100mg /IV /BD
* INJ FALCIGO 120mg /IV/OD
* INJ CEFTRIAXONE 2gm /IV/BD
* INJ DEXA 4mG /IV/BD
* INJ PANTOP 40mg /IV/OD
* T. TOLVAPTAN 15 mg / PO /OD
* ABG 8th HOURLY
* ORAL SUCTION - 2 HOURLY
* FLUID RESTRICTION < 1lit /day
ON 1.10.21 :
ON EXAMINATION :
Patient is on mechanical ventilator - CPAP -VC MODE
Psupp - 12
PEEP = 5 cm of H2O
FiO2 = 21%
* DIDNOT pass stools
* RR = 32cpm
* TEMP = 97.7 F
* BP = 100/ 70 mm hg
* PR = 85/ min
* SPO2 = 96%
* CVS - S1S2 heard
* RS - BAE (+)
* P/A - soft , distended
CNS - Dolls eye (+)
Pupils = B/L reacting to light
Tone - R L
UL Decreased
LL Decreased
reflexes - Right Left
B 2+ 2+
T 2+ 2+
S 2+ 2+
K 2+ 2+
plantaris mute mute
INVESTIGATIONS :
SERUM ELECTROLYTES -
Sodium - 130
Potassium - 4.1
Chloride - 91
Serum creatinine - 4.7
Serum urea - 214
Uric acid- 140
Calcium - 7 .0
Phosphate - 13.0
ABG:
PH - 7.34
PCO2 - 23.5
PO2 - 85.1
HCO3 - 12.6
Spo2- 89.6%
LFT:
Direct bilirubin - 0.2
Total bilirubin- 1.0
SGOT -954
SGPT - 699
ALP - 183
Total protein - 5.1
Albumin- 2.4
A/G ratio -0.9
Treatment :
PROPPED UP POSITION 30 DEGREES
* RYLES FEEDING - WITH 100ML MILK WITH PROTIEN POWDER 4th hrly
* INJ MEROPENEM 1gm /IV/BD
* INJ DOXYCYCLINE 100mg /IV /BD
* INJ FALCIGO 120mg /IV/OD
* INJ CEFTRIAXONE 2gm /IV/BD
* INJ DEXA 4mG /IV/BD
* INJ PANTOP 40mg /IV/OD
* T. TOLVAPTAN 15 mg / PO /OD
* ABG 8th HOURLY
* ORAL SUCTION - 2 HOURLY
* FLUID RESTRICTION < 1lit /day
* Monitor vitals daily
ON 2.10.2021 :
Patient is on mechanical ventilator .
CPAP
FiO2 - 21%
PEEP - 5cm H2O
Psupp- 10 cm H2O
Patient is drowsy and intermittent eye opening is present .
GCS - E4V1 M1
RR - 35cpm
PR - 88 bpm
BP - 110/60 mmHg
Temp- 99 °F
Pupils bilaterally reacting to light
Reflexes:
Biceps Triceps supinator ankle knee
UL + - - - -
LL + - - - -
Plantaris - mute
Tone - R L
UL Decreased
LL Decreased
TREATMENT:
PROPPED UP POSITION 30 DEGREES
* RYLES FEEDING - WITH 100ML MILK WITH PROTIEN POWDER 4th hrly
* INJ MEROPENEM 1gm /IV/BD
* INJ FALCIGO 120mg /IV/OD
* INJ Vancomycin 500mg /IV/BD
* INJ DEXA 4mG /IV/BD
* INJ PANTOP 40mg /IV/OD
* ABG 8th HOURLY
* ORAL SUCTION - 2 HOURLY
* FLUID RESTRICTION < 1lit /day
* Monitor vitals daily
* IVF 0.9% NS continuous infusion
* Creatinine clearance = 15 ml / min
Required dose - 15 mg / kg
On 3.10.21 :-
On examination
Patient is on Tps , drowsy and spontaneous intermittent eye opening is present.
GCS -E4V1M1
Pupils bilaterally reacting to light
RR - 29cpm
PR - 70bpm regular
BP - 110/70 mmHg
Temp- 98.6°F
Spo2- 97% @4lit of O2
Systemic examination:-
CVS :- S1S2 heard , no murmurs
RS :- NVBS+ ,crepts heard in the left side
PA:- Soft ,non tender
CNS :-
Reflexes:
Biceps Triceps supinator ankle knee
UL + - - - -
LL + - - - -
Plantaris - mute
Tone - R L
UL Decreased
LL Decreased
INVESTIGATIONS :
SERUM ELECTROLYTES -
Sodium - 125 mEq / L
Potassium - 4.3mEq/L
Chloride - 86 mEq/L
Serum creatinine - 5.0mg/dl
Serum urea - 290mg/dl
Uric acid- 14 mg/dl
Calcium - 7.0mg/dl
Phosphate - 13 mg/dl
ABG:
PH - 7.33
PCO2 - 23.7
PO2 - 65.3
HCO3 - 10.3
Spo2- 85.4%
LFT:
Direct bilirubin - 0.2
Total bilirubin- 0.51
SGOT -99
SGPT - 224
ALP - 181
Albumin- 2.0
A/G ratio -0.9
*Ecg:- QTc - 537 m sec
Hemogram :-
HB - 9.2 gm /dl
TLC- 31000 cells/mm3
Neutrophil- 93%
Lymphocytes- 4%
PCV -25.2
MCV - 70.8
Treatment :
PROPPED UP POSITION 30 DEGREES
* RYLES FEEDING - WITH 100ML MILK WITH PROTIEN POWDER 4th hrly
* INJ MEROPENEM 500mg /IV/BD
* INJ FALCIGO 120mg /IV/OD
* INJ Vancomycin 500mg /IV/BD
* INJ DEXA 4mG /IV/BD
* INJ PANTOP 40mg /IV/OD
* ABG 8th HOURLY
* ORAL SUCTION - 2 HOURLY
* FLUID RESTRICTION < 1lit /day
* Monitor vitals daily
* IVF 0.9% NS @75ml/hr
*Salt restriction < 2.4 gm / day
*Chest physiotherapy 2hrly
* T. TOLVAPTAN 15 mg / PO /OD
*Inj.sodium bicarbonate 50mEq/L in 100 ml NS over 1hr.
* T.shelcal 500 mg /RT/OD
* Inj. larix 20mg iv /BD
* T . Sevalemer 800 mg RT / BD
On 4.10.21 :-
On examination-
Patient is on TPS
Persistent vegetative state
Pupils bilaterally reacting to light
Spontaneous eye opening is present
RR - 31cpm
PR - 85bpm regular
BP - 120/80 mmHg
Temp- 94.7°F
Spo2- 98% @4lit of O2
Systemic examination:-
CVS :- S1S2 heard , no murmurs
RS :- NVBS+ , decreased breathe sounds in the left side
PA:- Soft ,non tender
CNS :-
Reflexes:
Biceps Triceps supinator ankle knee
UL + - - - -
LL + - - - -
Plantaris - mute
Tone - R L
UL Decreased
LL Decreased
Dolls eye sign (-) :- brain stem death
INVESTIGATIONS :
GRBS :- 253 mg/dl
RFT -
Sodium - 128mEq / L
Potassium - 4.4mEq/L
Chloride - 91 mEq/L
Serum creatinine - 3.9mg/dl
Urea - 299mg/dl
Calcium - 7.4mg/dl
Phosphate - 11.7 mg/dl
ABG:
PH - 7.3
PCO2 - 34.5
PO2 - 66.9
HCO3 - 16.7
Hemogram :-
HB - 11.1gm /dl
TLC-27000 cells/mm3
Neutrophil- 91%
Lymphocytes- 4%
PCV - 30.4
Platelet count- 2.83 lakh /mm3
2D Echo report :-
Treatment :
PROPPED UP POSITION 30 DEGREES
* RYLES FEEDING - WITH 100ML MILK WITH PROTIEN POWDER 4th hrly
* INJ MEROPENEM 500mg /IV/BD
* INJ FALCIGO 120mg /IV/OD
* INJ Vancomycin 500mg /IV/BD
* INJ DEXA 4mG /IV/BD
* INJ PANTOP 40mg /IV/OD
* ABG 8th HOURLY
* ORAL SUCTION - 2 HOURLY
* FLUID RESTRICTION < 1lit /day
* Monitor vitals daily
* IVF IonS ANd ors continuous IV fluids @150 ml / hr
*Salt restriction < 2.4 gm / day
*Chest physiotherapy 2hrly
* T. TOLVAPTAN 15 mg / PO /OD
* T.shelcal 500 mg /RT/OD
* Inj. larix 20mg iv /BD
* T . Sevalemer 800 mg RT / BD
* Inj manittol 100 ml / iv / bd
*Stool evacuation.
On 5.10.21:-
On examination--
Patient is in persistent vegetative state with GCS E4V1M1
Pupils Bilaterally reacting to light
Corneal reflex (+)
Conjunctival reflex (+)
Dolls eye sign (-)
Foley's catheter- day 5
Ryles tube- day 4
*Stools passed yesterday
I/O = 1200/1500ml
General examination:-
RR - 31cpm
PR - 84bpm regular
BP - 110/70 mmHg
Currently on Cpap mode of mechanical ventilator
FiO2 - 50%wit Spo2- 99%
PEEP - 5cm of H2O
INVESTIGATIONS :
RFT -
Sodium - 130mEq / L
Potassium - 4.3mEq/L
Chloride - 89mEq/L
Serum creatinine - 2.9mg/dl
Urea - 263mg/dl
Uric acid - 11.6 mg/dl
Calcium - 7.8mg/dl
Phosphate -10.2 mg/dl
ABG
PH - 7.2
PCO2 - 38.4
PO2 - 97.2
HCO3 - 14.7
Spo2- 92.6%
Hemogram :-
HB - 9.5gm /dl
TLC- 26000cells/mm3
Platelet count- 2.62 lakh /mm3
ECG:- Qtc - 152 m sec
TREATMENT:-
In view of ionic calcium and ecg changes-
* Inj 1amp calcium gluconate (10%in 10 ml) in 50 ml of 5 %dextrose over 10 to 20 min
|
Inj 6amp calcium gluconate in 500 ml NS @31.3 ml/hr over 24 hrs
* Inj MgSo4 1 amp in 500ml NS over 2 hrs .
On 6.10.21 :-
On examination--
Patient is in persistent vegetative state with GCS E1V1M1
Pupils Bilaterally reacting to light
Corneal reflex (-)
Conjunctival reflex (-)
Dolls eye sign (-)
Foley's catheter- day 2
Ryles tube- day 2
*Stools passed 2 days back
I/O = 3950/1750ml
General examination:-
RR - 36cpm
PR - 83bpm regular
BP - 90/60 mmHg
Spo2- 96%on mechanical ventilator on Cpap mode.
PEEP - 5 cm of H20
FiO2 - 50%
SYSTEMIC Examination:-
CVS :- S1S2 heard
RS :- BAE (+) ,clear
PA:- Soft ,non tender ,bowel sounds present
CNS :-
Reflexes:
Biceps Triceps supinator ankle knee
UL - - - - -
LL - - - - -
Plantaris - mute bilaterally
Tone - R L
UL Decreased
LL Decreased
Dolls eye sign (-) :- brain stem death
INVESTIGATIONS :
GRBS :- 156mg/dl
RFT -
Sodium - 136mEq / L
Potassium - 4.0mEq/L
Chloride- 98mEq/L
Serum creatinine - 2.3 mg/dl
Urea - 229mg/dl
Uric acid- 8.3 mg / dl
Calcium - 7.9mg/dl
Phosphate - 8.1mg/dl
LFT:
Direct bilirubin - 0.24mg/dl
Total bilirubin- 0.64mg/dl
SGOT -23 IU /L
SGPT - 61 IU/L
ALP - 180
Total protein - 4 g /dl
Albumin- 2.41 g /dl
A/G ratio -1.52
ABG:
PH - 7.03
PCO2 - 65.9
PO2 - 64.7
HCO3 - 16.3
Hemogram :-
HB - 8.8gm /dl
TLC- 34000cells/mm3
RCB - 3.46 million /cc
Platelet count- 2.5 lakh /mm3
TREATMENT:-
*Head end elevation
*Chest physiotherapy 2hrly
* ORAL SUCTION - 2 HOURLY
*Monitor vitals daily
*FreQuent Change of posture
*IVF 3 ions NS@100ml/hr
*Strict I/O charging
*RYLES FEEDING - WITH 100ML MILK WITH PROTIEN POWDER 4th hrly
* INJ Vancomycin 500mg /IV/BD
* INJ DEXA 4mG /IV/BD
* T. TOLVAPTAN 15 mg / PO /OD
*Inj 6amp calcium gluconate in 500 ml NS @31.3 ml/hr over 24 hrs
*GRBS 4th hrly
At 7:30pm :-
*Patient was on T-piece and was maintaining saturation for 2hrs .
Later her staturation level dropped around 75- 78% with T- piece and high flow of oxygen, so suction of ET and oral suction was done .
*Still saturation was very low so patien connected back to ventilator - CPAP mode
* patient was collapsed and central pulse was not felt then immediately CPR was started avoiding AHA guidelines ( ambubag connected while doing CPR)
7:30pm - BP not recordable, central pulse was absent
Inj . nor adrenaline 1mg iv given
7:35pm - BP not recordable, central pulse absent
Inj . nor adrenaline 1mg iv given
After 2cycles of CPR - patient revived
*Central pulse was felt,
HR on ecg 150 bpm ,regular and BP 80/60mmhg
*Patient was connected back to mechanical ventilator - ACMV - CPAP mode
With RR 14/ min , FiO2- 100% ,PEEP - 5 cm of H20 .
*Post PCR ecg changes was taken - showing sinus tachycardia.
Treatment:-
*Inj . Nor adrenaline 2amp in 50 ml NS @ 4ml/hr
* Inj. 1NS / iv / stat
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