39year old male

 CASE: 

A 39 Yr old male , electrician by occupation, resident of nalgonda and having 6 siblings .

His parents had no h/o DM,HTN,CAD,CKD.

Both his parents expired due to old age /? MI.

Pt attenders c/o

Since 10 days low grade fever and nausea and chills intermittently.

No h/o headache, blurring of vision or vomitings.

 -Loss of appetite since 2 days .

Since one day ,pt was unable to speak. but understanding commands .

Since yesterday morning ,pt was having 2 episodes of involuntary movements of b/l upper limbs and was drowsy since morning .

All his medical history started 8 month's ago .

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

He visited a hosp in Nalgonda ,where he was incidentally detected with creat of 5 mg/dl.

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 even had h/o wt loss and loss of appetite and low grade fever. 

He was having intermittent back pain since then .

After 2 months in August ,

** 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 and used unani medication.

Pt was neglected and using Unnani medications inspite of advising to use ATT.

**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 8 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.

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

No addictions.

O/E :-

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 

SECONDARY TO? POST ICTAL CONFUSION WITH ? ACUTE ISCHEMIC CVA( PARIETO TEMPORAL AREA) . or ? uremic encephalalopathy.

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.

Investigations:-

HB:- 3.8

PLT :- 61000

BGT:- 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

BO/PR MONITORING.

11) INJ. Pan 40 mg /Iv /Od

12) Inj. ZOFER 4 mg iv bd