39 M with Potts spine and paraplegia and bed sores.


Link to above data : http://patelsrighanashyam113.blogspot.com/2021/11/39m-with-altered-sensorium-and-bl-lower.html


A 39 Yr old male , electrician by occupation, with no significant medical history since childhood.

Chief complaints:-

**C/o decreased responsiveness since 2 days

**Not eating since 2 days 

**Decreased speech since 2 days--completely not talking since today morning.


Past illness:-


**8 months ago -- c/o low back ache , pain abdomen -- was told to have renal stones , meatal stenosis--underwent urethral dilatation in July 2021.

** August last week , 2021 -- c/o left lower limb weakness, slow gradually progressed to right LL -- B/L Paraplegia -- MRI was done --? Potts spine

Used ATT for 15 days and stopped , due to nausea and loss of appetite, patient was bedridden since, then , used unani medication.

**H.D was adviced 2 months ago - but didn't get it done due to fear of death ( among relatives deaths on H.D+)

** Since September 2021--Bed sores developed, 1 daily dressing done ,but patient was active and talks to everyone.

**C/o low grade fever since 10 days ,nausea , shivering+. No h/o loose stools , vomitings , headache, blurred vision.

** Since 1 day-- loss of appetite, unable to speak( sudden in onset) -- but obeying commands .

Since today-- Altered sensorium , no response to commands ,? Involuntary movements of b/l lower limbs(Rt>lft)

**K/c/o CKD on medication since 6 months-- went for low back ache and diagnosed with RENAL CALCULI WITH INCREASED SR.CREATINIE.

**K/c/o kochs spine (MRI)-- flaccid paraplegia since 2 months bed ridden ..used ATT for 15 days and stopped.

N/k/c/o DM , HTN, EPILEPSY, ASTHMA.


Personal history:-


** He has normal appetite , unmarried, mixed vegitation with regular bowel movements, he was on Foley's since 6 months .

No addictions.


ON EXAMINATION:-


Pallor+

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%

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(Rt>Lft)

Plantars-- B/l Flexion 

Power- --. RT. LT

 Upper limb - 5/5. 5/5

 Lower limb- plegia plegia(0/5)

Tone --

 Upper limb- Increased.Increase

 Lower limb- Decreased.decreased.

Reflexes:- RT. LFT

            B- absent. 2+

            T-. 3+. 3+

            S-. 2+. 2+

            K-. Absent. Absent

            A-. Absent. Absent.

Provisional diagnosis:- 

1) ALTERED SENSORIUM UNDER EVALUATION 

2) SECONDARY TO? Uremic encephalopathy or POST ICTAL CONFUSION WITH ? ACUTE ISCHEMIC CVA( PARIETO TEMPORAL AREA) 

3) ? TB - VASCULITIS/ SEPTIC INFARCT

4) PARAPLEGIA SECONDARY TO POTTS SPINE 

5) K/C/O CKD

6) ANEMIA UNDER EVALUATION

7) GRADE 3 BED SORE.










Examination videos : 

https://youtube.com/shorts/pr0M1wdFQVU?feature=share 

https://youtube.com/shorts/cNiwKIL0044?feature=share 


https://youtube.com/shorts/o_i7w6dgtb0?feature=share 

https://youtube.com/shorts/FGVOnAwEyUg?feature=share 








Investigations:-

HB:- 3.

PLT :- 6100

BGT:- A Positiv

Na-13

K-4.

Cl-9

Sr.creat-4.

LFT:

TB- 0.9

DB-0.2

SGOT-1

SGPT-2

ALP-37

TP- 4.

ALBUMIN:-2.

A/G :-0.7

LDH:- 22

Blood urea- 24

Rbs-14

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
BO/PR MONITORING.
11) INJ. Pan 40 mg /Iv /Od
12) Inj. ZOFER 4 mg iv bd

"Pt underwent Doppler yesterday-thrombus present

Should we start him on clexane 40 mg bd, but his platelet count is-50k.



S- patient is in altered sensorium .

 

O - GCS - E4V1M4

      Temp-99 degrees F

     PR-130/min 

     Bp-100/80mmHg with NA 18 ml/hr

Tremors of both upper limbs -? Uremic tremors reduced 

CNS - pupils - NSRL

Tone - hypertonia in upper limbs .

Hypo in lower limbs 

Power -upper limb -3/5( resistance couldn't be tested because of altered sensorium ) 


lower limb -0/5 

Reflexes - rt. Lft 

        B. +3 +3

       T. +3. +3 

        P mute mute

        K. -. - 

        A. -. - 

       

No meningeal signs . 


A - Altered sensorium secondary to uremic encephalopathy

Uremic tremors .

Focal seizure with secondary generalization

Paraplegia - secondary to Potts spine .

Anemia - ? Anemia of chronic inflammation

Grade 4 bed sore .

CKD V- with severe metabolic acidosis

Old lacunar infarct in Right caudate nucleus

Left lower limb DVT 


Plan - 

Plan - 

1)Iv fluids -1 NS @75 ml/hr

2)Ryles tube feeds(milk+protein powder;water) - 4th hrly .

3)ATT 

4)INJ OPTINEURON 1 AMP IN 100ML NS/IV/OD

5)INJ.LEVIPIL 500 MG IV/BD

6)INJ.CEFTRIAXONE 1 GM/IV/BD

7)INJ.CLINDAMYCIN 600 MG/IV/TID

8)INJ NOR-AD DS-2 AMP IN 50ML NS IV @6ML/HR

9)INJ.PAN 40 MG IV/OD

10)INJ.NEOMOL 1GM IV/SOS IF TEMP >102

11)INJ.ZOFER 4 MG IV/TID

12)INJ.LEVOFLOXACIN 750 MG IV

13)GRBS 8TH HOURLY

14)BP/PR/TEMP MONITORING 2ND HRLY

15)DVT STOCKINGS 


1 session of dialysis done yesterday along with one PRBC transfusion .





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