Case of a 52 year old female.

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CASE : 

A 52 year old female,house wife  resident of narketpally came to the causality in a drowsy state

She was apparently asymptomatic 1 week back,when she sustained an injury to the left LL(shin according to attenders but wound not visible outside -outside  x-rays normal ),after which she developed pain and edema ,she was treated outside with pain killers ,had restricted movements and hence did not move much and lied on bed most of the time ,walked with support and gradually the swelling got decreased to some extent . 5 days later she again visited RMP as her appetite was decreased and also associated with generalised weaknesses  and left lower limb pain and also hip( localisation not possible )for which pt was given  IV fluids and pain killers.

This morning after eating ,she had sudden onset of around 10-15 vomiting episodes with nausea then she suddenly became drowsy ,while she was being shifted here,there is irrelevant talk and pt was incoherent.

On presentation, pt was unconscious with 

E1V1M4 to E1V1M1

Past history : 

No H/o diabetes, hypertension,asthma epilepsy,TB 

No similar complaints in the past 

No history of any surgeries or blood transfusions

Personal history : 

Diet - Veg 

Appetite - decreased 

Sleep - adequate

Bowel and bladder movements : Regular 

No known allergies

No history of alcohol consumption or smoking

On examination: 

Pt is stupourous ,withdrawal from pain 

Febrile to touch:100°F

PR: 86bpm

BP: 130/70 mmHg

RR: 24

CVS: S1, S2 heard

RS: BAE present ,end inspiratory wheeze in all areas ,

Spo2: 96%on room air

P/A: obese ,non tender ,bowel sounds sluggish 

CNS: 

Pupils - right side -NS RL 

Left side - post cataract surgery r/n to light 

Gag present

Tone : normal b/l

Reflexes

       Lt. Rt

B. 2+. 2+

T. 2+. 2+

S. 2+. 2+

K 2 +. 2+

A. 2+. 2+

P. Upgoing. Upgoing

Provisional diagnosis:

Altered sensorium under evaluation secondary to hyponatremia( euvolemia)?SIADH 

Sepsis secondary to ?cellulitis ? Typhoid

with complete right bundle branch block 

Investigations : 

RFT : 

Urea - 15 

Creatinine - 0.6 

Uric acid - 2

Calcium - 8.6

Phosphorus - 3.2

Na+ : 118 

K+ : 3.8 

Cl- : 76 

LFT : 

TB : 0.88

DB : 0.20

AST : 26

ALT : 13

ALP : 177 

TP : 5.5 

ALB : 3.1

A/G : 1.33 

Serum osmolality :

Serum sodium @ 10pm 

Urinary electrolytes : 

ECG : 

CHEST X RAY : 

MRI BRAIN : 

TREATMENT : 

1) Propped up position 

2) IVF 3% Nacl @10 ml/hr 

3) Ryles catheterization 

4)Foley's catheterization 

5)Inj.Piptaz 4.5 gm /IV/BD

6) RT feeds : 100ml water 2nd HRLY 

                        50 ml milk 4rth HRLY 

Day 2 of admission : 

Pt is stupourous ,withdrawal from pain 

Febrile to touch:100°F

PR: 86bpm

BP: 130/70 mmHg

RR: 24

CVS: S1, S2 heard

RS: BAE present ,end inspiratory wheeze in all areas ,

Spo2: 96%on room air

P/A: obese ,non tender ,bowel sounds sluggish 

CNS: 

Pupils - right side -NS RL 

Left side - post cataract surgery r/n to light 

Gag present

Tone : normal b/l

Reflexes

       Lt. Rt

B. 2+. 2+

T. 2+. 2+

S. 2+. 2+

K 2 +. 2+

A. 2+. 2+

P. Upgoing. Upgoing

Diagnosis:

Altered sensorium under evaluation secondary to hyponatremia( euvolemia)?SIADH 

Sepsis secondary to ?cellulitis ? Typhoid

with complete right bundle branch block 

Investigations : 

RFT : 

Urea - 13

Creatinine - 0.6 

Uric acid - 2

Calcium - 8.5

Phosphorus - 3.5

Na+ : 128 

K+ : 3.9

Cl- : 90

ABG : 

 

Electrolytes @ 2pm : 

Na+ : 123

K+ : 3.9 

Cl- : 85 

  

Electrolytes @10 pm : 

Na+ : 123

K+ : 3.9 

Cl- : 85 

Pt developed bed sore on her right 

buttock : 

Treatment : 

1) Propped up position 

2) IVF 3% Nacl @10 ml/hr 

3) Inj.PANTOP 40 mg PO/OD

4)Inj.Piptaz 4.5 gm /IV/TID

5) Nebulization with budecort @ 8th HRLY and 

                                    Asthalin @12th HRLY 

6) RT feeds : 100ml water 2nd HRLY 

                        50 ml milk 4rth HRLY 

Day 3 of admission : 

Still in altered sensorium 

And attendant complaints of her having on and off fever episodes and no improvement in sensorium since admission 

O - 

However her GCS has gone up from E1M1V1 to E2V1M1 

RR - 35 cpm 

PR - 124bpm

BP- 120/70mmhg

Temp - 101 F

Spo2 - 98%on 15L RA

CNS -

E2M1V1

Pupils - 

Bilaterally reacting to light 

Left post cataract surgery 

Hypotonia + in all 4 limbs 

Reflexes- 

Bilateral biceps +

Plantars - Mute 

Corneal and conjunctival reflexes +

No meningeal signs 

Lungs - Bilateral inspiratory crepts in all Lung fields

And expiration wheeze in all Lung fields

Cvs - S1,S2+

Per Abdomen - soft

Bowel sounds +

A -

Altered senorium secondary to ? Hyponatremia 

Sepsis secondary to ? cellulitis 

? Typhoid

With complete RBBB 

P - 

LP was done will be updating shortly

Continuing her on 

Inj 3% NACL @ 10ml/hour 

Inj Pantop 40mg IV OD

Inj Piptaz 4.5 gm/IV/TID

Neb with budecort 8th hourly and Asthalin 12 hourly 

RT feeds - 100ml milk and 50ml free water 2nd hourly 

Tab Dolo 650mg sos 

Hemogram : 

Hb - 11.6

TLC : 46500 

Plt : 39900

RBC : 4.56 

ABG @ 6am : 

Chest xray : 

ECG : 

 

ABG @ 12pm : 

After lp,csf was sent for analysis : 

Volume : 1ml

Appearance : clear 

Color : slightly reddish 

TC - 436 (corrected WBC count ) 

Dc - 90% neutrophils ,10% lymphocytes

RBC - 14650

Others : nil

Awaiting cytology reports

Csf sugar : 25 

Csf protein : 29 

Csf chloride : 116

RBS : 85

Electrolytes @6pm : 

Na - 122

K - 4.2

Cl - 80 

Day 4 :

52 year old woman, 

ICU bed 1

Still in altered sensorium 

And attendant complaints of her having on and off fever episodes 

 no improvement in sensorium since admission 

O - 

 GCS E2V1M1 

Pt is on mechanical ventilation 

Simv - vc mode 

Tv - 400 ml

PEEP - 5 cm of h20 

FiO2 - 30%

RR - 40 cpm 

PR - 94bpm

BP- 110/60mmhg

Temp - 37.3 C

Spo2 - 98%on 15L RA

CNS -

E2M1V1

Pupils - 

Bilaterally reacting to light 

Left post cataract surgery 

Hypotonia + in all 4 limbs 

Reflexes- 

Bilateral biceps +

Plantars - Mute 

Corneal and conjunctival reflexes +

No meningeal signs 

Lungs - Bilateral inspiratory crepts in all Lung fields

And expiration wheeze in all Lung fields

Cvs - S1,S2+

Per Abdomen - soft

Bowel sounds +

A -

Altered senorium secondary to ? Hyponatremia 

Sepsis secondary to ? cellulitis ? Pyogenic meningitis

? Typhoid

With complete RBBB 

P -

Inj.Dexa 4mg iv/ bd

Inj. Ceftriaxone 2 gm iv. Bd

Inj Pantop 40mg IV OD

RT feeds - 100ml milk and 50ml free water 2nd hourly

Investigations : 

Hb - 11 

TLC - 52500

Pcv - 29.2

Plt - 3.48 

TB - 3.46 

Db - 0.63 

AST - 1036 

Alt - 530 

TP - 5.3

Alb - 2.73 

A/g - 1.06 

ABG : 

pH - 7.527 

pCo2 - 13.7 

PO2 - 106 

HCo3 - 17.4 

Rft : 

Urea - 137

Creat - 2.8

uric acid - 11.5 

Ca- 10.2 

Phosphate - 11.2 

Na - 119 

K - 4.3 

Cl - 75 

01/10/21

Icu bed 1 

Altered sensorium secondary to hyponatremia

? Pyogenic meningitis

S: Patient sensorium improved and on ventillator CPAP VC mode 

O: Bp 110/80 mm hg 

Pr 112 bpm 

Spo2 99% on fio2 21% 

Grbs 120 mg dl 

A: Etiology of altered sensorium - Hyponatremia 

? Meningoencephalitis 

Plan: Extubation 

2/10/21

52 year old woman, 

ICU bed  1

Pt is drowsy , intermittent spontaneous eye opening present.

O - 

 GCS E4VTM1

RR - 35 cpm 

PR - 88bpm

BP- 110/60mmhg

Temp - 99 F

Spo2 - 98%on T piece (8lot o2)

CNS -

E4VtM1

Pupils - 

Bilaterally reacting to light 

Left post cataract surgery 

Hypotonia + in all 4 limbs 

Reflexes- 

Bilateral biceps +

Plantars - Mute 

Corneal and conjunctival reflexes +

No meningeal signs 

Lungs - Bilateral inspiratory crepts in IAA,ISA.

Cvs - S1,S2+

Per Abdomen - soft

Bowel sounds +

A -

Altered senorium secondary to ? Hyponatremia (?SIADH)

  ? Pyogenic meningitis

?Pre renal aki

Grade 1 bed sore present.

P - To extubate if pt is conscious and maintaining sats .

Inj.Dexa  4mg iv/ bd

Inj. Ceftriaxone 2 gm iv. Bd

Inj Pantop 40mg IV OD

RT feeds - 100ml milk and 50ml free water 4th hourly.

Lft trends in this patient : 

3/10/21

S: Patient in ? persistive vegetative state

O : Bp 110/70 mm hg

Pr 70 bpm

Cvs : s1 s2 heard no murmurs

Rs bae 

P/a soft 

Assesment: Hyponatremia resolved yet patient gcs not improved

Plan: extubation

 4/10/21 

S: Patient in ? persistive vegetative state.

GCS - E1VtM3

Pupils - NSRL ( left eye post cataract surgery)

O : Bp 140/90 mm hg

Pr 80 bpm

Cvs : s1 s2 heard no murmurs

Rs bae present . 

P/a soft 

I/O - 2700/1700ml

Assesment: Altered sensorium secondary to Meningitis/hyponatremia .

Hyponatremia secondary to SIADH .

? PYOGENIC MENIGITIS.

ATN /AKI .

 ? ISCHEMIC / Drug induced hepatitis - resolved.

Grade 2 bed sore.

Plan: Pt maintaining on T piece .

But still not conscious enough for extubation.

Does she require hemo-dilaysis ?? 

Repeat 2d echo .

 

ABG : 

RFT (YESTERDAY ) - urea - 290 ; creat - 5 ; Na - 125 ; k- 4.3 ; cl- 86 mg/dl. uric acid - 14 (high) 

S calcium - 7 

corrected ca - 8.6 mg/dl

Qtc prolonged - 537 msec.

06/10/21 

S: Patient in ? persistive vegetative state.

GCS - E4VtM1

Pupils - NSRL ( left eye post cataract surgery).

passed stools.

Bed sore increasing ( grade 2 ) .

Pt on Mechanical ventilator - CPAP Vc mode .

pressure support -12 ; peep -5 cmof h20 .

Fio2- 40 %.

Pt also maintaining on T piece intermittently.

O : Bp 110/70 mm hg

Pr 88 bpm.

Spo2- 94%.

Cvs : s1 s2 heard no murmurs

Rs Bae present . 

P/a soft 

Assesment: Altered sensorium secondary to Meningitis/hyponatremia .

Hyponatremia secondary to SIADH .

? PYOGENIC MENIGITIS.

ATN /AKI - resolving

Grade 2 bed sore.

Hypocalcaemia ( Ionised calcium - 1.94 mg/dl) - very low. - correction was given .

Yesterday rft - Urea - 263 ; creat - 2.9 

Na- 130 ; k- 4 .3 ; cl-89.

Creat decreased from 4.8 to 2.9 

P- TO extubate.

But she might require tracheostomy mostly.

Cause for hypocalcaemia ?

07/10/21

S: Patient in ? persistive vegetative state.

GCS - E1VtM1

Pupils - NSRL ( left eye post cataract surgery).

passed stools.

Bed sore increasing ( grade 2 ) .(dressing done)

S- Yesterday night , patient saturation were falling on T piece (75-78%) . So immediately oral and ET suction was done , and pt was connected back to ventilator with fio2- 100% .

Meanwhile pt collapsed and her central pulse was absent. So cpr was started according to AHA guidelines.

After 2 Cycles of cpr ,pt revived . She was connected back to mechanical ventilator - ACMV -VC mode .

RR- 14/MIN ; FIO2-100% ; VT -420 ml; PEEP- 5 cm.

of h20 .

Post CPR vitals : 

Bp- 80/60 mmhg ( started on noradrenaline@ 4ml/hr) 

Pr- 150 bpm ; SPO2- 100% .

Today morning vitals : 

O : Bp 120/70 mm hg - on NA @2 ml/hr 

Pr -92 bpm.

Spo2- 100%

Cvs : s1 s2 heard no murmurs

Rs Bae present . 

P/a soft .

Assesment: Altered sensorium secondary to Meningitis/hyponatremia .

Hyponatremia secondary to SIADH .

? PYOGENIC MENIGITIS.

ATN /AKI - resolving

Grade 2 bed sore.

Hypocalcaemia ( Ionised calcium - 1.94 mg/dl) - very low. - correction was given .

Post cpr status.

Yesterday rft - Urea - 229 ; creat - 2.3

Na- 136 ; k- 4 ; cl-98. 

P- TO extubate.

But she might require tracheostomy mostly. 

Post cpr ecg - showing rbbb and t wave inversions in v1-v3. Poor r wave progression 

lumber puncture done 

CSF cell count 2 

08/10/21

S: Patient in ? persistive vegetative state.

GCS - E1VtM1

Pupils - NSRL ( left eye post cataract surgery).

passed stools.

Bed sore increasing ( grade 2 ) .(dressing done)

O : Bp 110/70 mm hg 

Pr -82 bpm.

Spo2- 98%

Cvs : s1 s2 heard no murmurs

Rs Bae present . 

P/a soft 

Assesment: Altered sensorium secondary to Meningitis/hyponatremia .

Hyponatremia secondary to SIADH .

? PYOGENIC MENIGITIS.

ATN /AKI - resolving

Grade 2 bed sore.

Hypocalcaemia ( Ionised calcium - 1.94 mg/dl) - very low. - correction was given .

Post cpr status.

Lp done yesterday . Cell count - 2 .; Rbc - nil

Dc - 100% lymphocytes .

Yesterday rft - Urea - 223 ; creat - 2

Na- 135 ; k- 3.9 ; cl-97

P - plan for tracheostomy. 

09/10/21 

S: Patient in ? persistive vegetative state.

GCS - E2VtM2

Pupils - NSRL ( left eye post cataract surgery).

passed stools.

Bed sore increasing ( grade 2 ) .(dressing done)

Able to move her right fingers intermittently. 

O : Bp 140/70 mm hg 

Pr -82 bpm.

Spo2- 98%. On SIMV mode - RR- 14/min ; fio2- 40%

peep-5 cm of h20 ; TV-420 ml.

Cvs : s1 s2 heard no murmurs

Rs Bae present . 

P/a soft 

Assesment: Altered sensorium secondary to Meningitis/hyponatremia .

Hyponatremia secondary to SIADH .

? PYOGENIC MENIGITIS.

ATN /AKI - resolving

Grade 2 bed sore.

Hypocalcaemia ( Ionised calcium - 1.94 mg/dl) - very low. - correction was given .

Post cpr status.

P - plan for tracheostomy today at 9 am .

 10/10/21 

Tracheostomy POD -DAY 1 

S: Patient is conscious , 

GCS - E4V1M4

Pupils - NSRL ( left eye post cataract surgery).

passed stools.

Bed sore increasing ( grade 2 ) .(dressing done)

Able to move her right upper limb and lower limb. Left side no movements noted.

O : Bp 130/70 mm hg 

Pr -87 bpm.

Spo2- 95%. Ventilator connected to tracheostomy tube . - On ACMV-VC mode - RR- 14/min ; fio2- 21%

peep-5 cm of h20 ; TV-380 ml.

Cvs : s1 s2 heard no murmurs

Rs Bae present . 

P/a soft 

GRBS -129 mg/dl

I/O- 3400/2200 ml

CNS - POWER -         R.      L

 •                    UL-    3/5.    0/5

 • .                  LL -3/5         0/5

 • TONE - Decreased all 4 limbs .

 • Assesment: Altered sensorium secondary to Meningitis/hyponatremia .

Hyponatremia secondary to SIADH .( resolved).

? PYOGENIC MENIGITIS.

ATN /AKI - resolved

Grade 2 bed sore.

Post cpr status.

Tracheostomy- Pod day 1

Rft - urea - 129 ; s creat - 1 ; Na- 134 ; k-2.7 ; cl-101

hb-8.3 ; tlc - 30k ; plt-1.51

abg - Ph - 7.41 ; pco2- 25 ;po2-112 ; hco3-19.3 

P- 2 nd hrly tracheostomy tube suctioning.

Deflate cuff 2nd hrly for 5 min and re-inflate.

11/10/21 

Subjectively : patient nodding her head for commands and able to lift her right upper and lower limb

Objectively : pupils Both eys  reacting to light 

GCS : E4V1M4 

Passed stools 

No fever spikes 

Grbs : 172 mg/dl 

I/o : 2600/1600

Bp 140/80 mm hg 

Pr : 90 bpm

Spo2 : 100% on 2 L O2 on T piece 

Cvs s1 s2 heard no murmurs

Rs bae+

P/a soft nt 

Cns : tone decreased in all limbs 

Power : 3/5 on right side 

0/5 on left upper and lower limbs

Assesment : Altered sensorium secondary to pyogenic meningitis / Hyponatremia (SIADH) resolved 

Aki resolved : MODS resolved 

Grade 2 bedsore 

Post cpr status 

Tracheostomy pod 3

Plan : An Mri to rule out ic bleed for ?hemiparesis 

12/10/21 

At 2:00 am patient suddenly had gasping with ecg showing bradycardia PR:20 cpm and spo2 60 % on ventillator of fio2 90

And patient had no pulse 

Cpr was initiated and atropine 1 mg was given and 5 cycles of cpr was done then patient had suctioning was done and mucus plugs were removed 

Patient was revived with spo2 of 100% 

Pupils dilated fixed 

Bp 90/80 mm hg 

Pr 160 bpm

Grbs 101 mg/dl

Cvs s1s2 heard 

Rs : Bae+ 

P/a: soft ,NT

Post cpr Abg :

Ph :7.031

Pco2 64.9

Po2:155

Hco3:13.5

Assesment : Bradycardia secondary to hypoxia( ET obstruction with mucus plug)

8::00am 

 Subjectively : patient comatose 

Objectively : pupils Both eys  dilated and fixed.

Corneal reflex and conjunctival reflex absent 

Dolls eye negative

GCS : E1v1M1

Passed stools 

3 fever spikes 

Grbs : 172 mg/dl 

I/o : 3500/1500

Bp 80/60mm hg 

Pr : 90 bpm

Spo2 : 100% on ACMV mode 

Fio2 500

Peep 5 cm h2o

Cvs s1 s2 heard no murmurs

Rs bae+

P/a soft nt 

Cns : tone decreased in all limbs 

Power : 0/5 on right side 

0/5 on left upper and lower limbs

Assesment : Altered sensorium secondary to pyogenic meningitis / Hyponatremia (SIADH) resolved 

Aki resolved : MODS resolved 

Grade 2 bedsore 

Post cpr status 

Tracheostomy pod 3

?Hypoxic Ischaemic encephalopathy

Plan : suctioning every 2nd hourly 

Abg morning ph:7.27

Pco2:54 

Po2:38 

Hco3:21

Plan : Inj Noradrenaline infusiom 4ml/hr