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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
UNIT 6 ADMISSION
60 year old male farmer by occupation came with
C/O of shortness of breath since yesterday
C/O Decreased urine output since yesterday
Since 1 year patient complains of multiple joint pains with restricted movements for which he used ayurvedic medication . H/o trauma to the spine in the field during work ,since then patient not able to use left lower limb and Right upper limb . Three months ago h/o slip and fall when patient was going to washroom, h/o injury to right elbow and inability to walk since then , so patient was taken to the hospital MRI spine was done ? Dislocation of vertebrae and was adviced for surgery but they didnot get it done and was bedridden since then.
Since last 2 months patient conplains of loss of sensations in bilateral lower limbs and stiffning of bilateral upper limbs , and complains of urinary incontinance patient not able to sense fullness of urine since 2 mon and is put on foleys .
Since yesterday no urine in foleys and at outside hospital RMP removed foleys and on attempting to put another foleys patient had hematuria and was referred here .
SOB since 1 day more on supine position .
C/o loose stools 2 episodes since morning .
No h/o cold , cough, fever , vomitings .
Non Hypertensive
Non diabetic .
GENERAL EXAMINATION
Flexion deformites of right upper limb and left lower limb .
Burn injury is present on right thigh .
Odema of feet upto knees.
No pallor, icterus, cyanosis , clubbing , lymphadenopathy .
VITALS
TEMP - AFEBRILE
BP - 70/ 50 MMHG
PR - 97 / MIN
SPO2 - 96% ON RA
GRBS - 114 mg %
SYSTEMIC EXAMINATION
CVS : S1, S2 +
RS : BAE + , NVBS
P/A : SOFT , NON TENDER
BOWEL SOUNDS +
CNS :
HMF - INTACT
CRANIAL NERVES - INTACT
SENSORY SYSTEM -
NO SENSATIONS IN BILATERAL LOWER LIMBS .
CRUDE TOUCH IS PRESENT UPTO LEVEL OF T5 - T6
FINE TOUCH IS PRESENT TILL T2.
PAIN SENSATION IS PRESENT UPTO LEVEL OF T2
VIBRATION SENSATION
R L
Wrist Lost Lost
Elbow + +
LL Lost Lost
PROPRICEPTION Lost Lost
Motor examination
Tone - coudnt be elicited as patient is not able to compleatly extend limbs
Power R L
Upper limbs 4- /5 4- / 5
Lower limbs 0/5 0/5
REFLEXES
B T S K A
R 3+ 3+ 3+ - -
L 3+ 3+ 2+ - -
Plantar Right - withdrawl
Plantar left - mute
PROVISIONAL DIAGNOSIS
SEPTIC SHOCK
septic shock+(?typhoid)
autonomic dysfunction
?septic shock as suggested by orthopaedics
cervical canal stenosis(C3-C6)
mild stenosis in lumbar and dorsal vertebrae
?hfpef
hypoalbuminemia.
PLAN OF CARE
- IVF 2 UNITS OF NS @ 75 ML/HR
- INJ. NORADRENALINE TO MAINTAIN BP > 75 ML / HR @ 8ML/HR
- INJ. LASIX 40 MG IV BD
- SALINE GAUGE DRESSING FOR RIGHT THIGH.
- PROTEIN POWDER 2 TABLE SPOONS IN 100 ML MILK BD
- 2 EGG WHITES / DAY.
MRI 20/8/21
ICU bed 6
S-c/o sob relieved, unable to extend his legs fully ,
no sensation of passing stools or urine
not able to get up from bed,move on the bed without help of attender .
fever spikes+
O- pt is c/c/c
pt had one episode of sudden unresponsiveness with only central pulses and bp not recordable ,revieved with inj noradrenaline 2 mg/iv/stat
such episodes are occuring once /day.
burning injury on the right thigh
flexion at hip and knee joint
?contracture ,
afebrile
pr- 98/min
bp-.80/60 mmhg with inj norad ds @22ml/hr,inj dobutamine @4ml/hr
cvs:jvp raised
s1:s2+
r s:bae+nvbs
spo2: 98%on room air
cns:hmf intact
tone: increased in all four limbs
motor:
power :LL: 2/5 in both limbs
UL: 4-/5 in both limbs
unable to roll on the bed
able to lift neck above the pillow
reflexes: biceps:3+(b/l)
triceps:3+
supinator+1
no knee ankle
plantar:mute (b//l)
abdominal reflexes:absent
sensory:
no pain,temp,crude ,fine touch in dermatomes below T4-T5
A- septic shock+(?typhoid)
autonomic dysfunction
?septic shock as suggested by orthopaedics
cervical canal stenosis(C3-C6)
mild stenosis in lumbar and dorsal vertebrae
?hfpef
hypoalbuminemia.
P- inj norad ds @ 22ml/hr
inj dobutamine @4ml/hr
inj Meropenem 1gm/iv/bd
syp sucral fate 10ml/bd
tab dolo 650mv/po/sos.
when trying to titre ionotropes there is wide fluctuating bp-and a state of unresponsiveness
,pt is revived only with a bolus dose inspite of infusion.
further management?
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