65 year old female with community acquired pneumonia with type 1 respiratory failure with hyperglycemia (resolved) with chorea(resolved) with diabetic nephropathy with recurrent uti with iron deficiency anemia

 M.Sri Nithya 

Roll. No-86

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Chief compliants

A 65 yr old female patient came to casualty with complaints of weakness of lt upper limb since 1 day 

Cough since 4 days 

HOPI 

Pt was apparently asymptomatic 1 week ago then she developed generalised weakness , fell down from bed and complaints of pain in the hip 

Involuntary movements of lt upper limb since 1 day to and fro 

No history of speech abnormalities , weakness in the upper limb and lower limb .

No H/o memory loss and abnormal posturing .

Complaints of cough since 4 days ,it is productive scanty sputum - white to yellow ,non blood stained and non foul smelling 

H/o inadequate controls of sugars from 4 months 

N/H/o vomiting ,sob,loose stools ,pain abdomen

K/c/o type 2 DM since 30 yrs on infusion since 10 yrs 

( Insulin - lispro 20-x-20 )

K/c/o HTN from 20 yrs on T prolomet - xl 50 mg 

                                                T. Atenolol 25 mg po/ od at 10 am


K/c/o hypothyroidism from 15 yrs on thyronorm 75 mcg

Previous treatment history

Hospitalised 1 yr ago for UTI 

https://rishikoundinya.blogspot.com/2022/08/54-year-old-female-with-uncontrolled.html?m=1

H/o hysterectomy 30 yrs ago 

Personal history


DIET- mixed

Appetite: Normal

Bowel and bladder movements are regular

Sleep: adequate 

No allergies

Chews tobacco 

Chews betel nut and betel leaf twice daily 


General examination

Pt is conscious , incoherent, cooperative

Pallor present

No 

      Icterus

      Cyanosis

       Clubbing

       Lymphadenopathy

Edema present B/L pitting type extending up to knee

Vitals

         BP 110/70mmhg

         PR 76 BPM

         RR 18 cpm

         Spo2 98

Grbs. 315 mg/ dl

Systemic examination

       Respiratory examination

        BAE +ve and normal vesicular breath sound heard 

        No crepts heard 

      CVS examination

       S1S2 heard 

        No murmurs heard

        Abdomen examination

        Soft non tender

        No hepatomegaly and splenomegaly

CNS examination 

Higher mental functions intact

Conscious , coherent non cooperative 

Speech normal 

Motor system Rt. Lt 

                       Tone. Ul. N. N

                                  Ll. N. N

                  

         Power Ul. N. N

                                               Ll. N. N

   Reflexes B. T. S. K. A

              Rt. 1+. 1+. _. 1+. _ 

              Lt. 1+. 1+. _. 1+. _

Plantars. B/L flexors

No cerebellar and meningial signs 


Provisional diagnosis 

Hyperglycemia with hemiballismus K/C/o type 2 DM with HTN since 20 yrs 

K/c/o hypothyroidism since 15 yrs 

K/c/o CKD since 2 yrs 

Diabetic nephropathy with recurrent UTI with iron deficiency anemia



Investigation 


Usg abdomen    

B/l grade 1-2 RPD changes with raised echogenecity 

Lab investigation 









X ray pa view 



Ecg




Treatment

1 inj HAI 6 units /IV/ stat followed by insulin infusion 1 ml/ hr

2 IVF NS @ 75 ml/ hr

3 5 D @ 50 ml / hr 

4 check grbs hrly and infusion 

5 monitor vitals and inform sos 

6 NBM till further orders and I/O charting 


Fever chart








Dr Aashitha Sr

Dr pradeep pg 3

Dr Vinay pg 3

Dr Narsimha pg 2

Dr Ajay pg 1

Dr prachethan pg 1

Dr M. Sri Nithya (intern)

Dr. K. Rithika(intern)



ICU bed 4 

New case 

65/F


S

No fever spikes 

Stools passed 

Involuntary movements of Lt upper limb 

O

 Pt is c/c/ c

Bp 150/80 MMHG

Pr. 82 bpm

Grbs. 155 mg/ dl. 

Temp 98.2 F 

CVS S1S2 HEARD no murmurs

RS BAE + NVBS + 

P/A soft nontender 

CNS HMF intact

GCS. E4 V 5 M 6


A

Hyperglycemia with hemiballismus K/C/o type 2 DM with HTN since 20 yrs 

K/c/o hypothyroidism since 15 yrs 

K/c/o CKD since 2 yrs 

Diabetic nephropathy with recurrent UTI with iron deficiency anemia


P 


 inj HAI ( 1 ml + 39 ml NS ) @ 2 ml / hr ( it will be increased or decreased based on grbs values) 


 IVF NS @ 75 ml/ hr

   IVF 5 D. 50 ml/ hr


 hourly grbs monitoring and monitor vitals and inform sos 

 

T promolet Xl 50 mg po/od at 8 am

 

T thyronorm 75 mcg po/ od @ 7 am 


T tetabenazine 12.5 mgPo/ od


On 08/2/23-

Referred to the department of ophthalmology I/v/ 0- diabetic and hypertensive retinopathy -

No diabetic retinopathy changes noted

No hypertensive retinopathy changes noted.

On 9/2/23-

Referred to the department of neurology I/v/ o generalised weakness and involuntary movements of left upper limb. 

On 9/2/23-

Referred to the department of anaesthesia as patient has to undergo mri under general anaesthesia 

Referred to the department of dermatology I/v/o dry, brown scaly lesions on both legs.

Diagnosed as senile xerosis. 

Bacterial culture and sensitivity report-



On 13/2/23-

Referred to the department of pulmonology I/v/o- hospital acquired pneumonia with type 1 respiratory failure.

Adviced-

Cst

Syp. Ascoryl 2 tbsp po/tid

Nebulisation with mucomist BD

Chest xray PA view-




2d echo -



Treatment-

Head end elevation

Inj. Augmentin 1.2g/ iv / bd

T. Thyronorm 75 mcg po/od

T. Promet-xl 50 mg po/bd 

T. Tetrabenazine  125 mg po/tid

Inj. HAI s/c tid

8am- 8 units

1pm- 8 units

8pm- 8 units

Liquid paraffin for l/a bd

T. Teczine 5 mg po / sos

Nebulisation with duolin -6th hourly budecort -12 th hourly

 Inj. Lasix 40 mg iv/bd

IVF- NS@80 ml /hr

Grbs monitoring

Input and output monitoring 








14/02/23

ICU-BED NO. 2

UNIT 2

Dr Aashitha(SR)

Dr Pradeep PGY3

Dr Vinay PGY3

Dr Narsimha PGY2

Dr prachethan PGY1

Dr Ajay PGY1


S

C/O COUGH WITH EXPECTORANTION DECREASED


STOOLS PASSED

NO FEVER SPIKES SINCE YESTERDAY NIGHT



O


PT IS C/C/C

TEMP-AFEBRILE

PR-78Bpm

SPO2-99% WITH 2L OF O2

BP-120/60mmhg

Grbs-

8 am -170 mg/dl

8 units hai given

1pm - 132 mg/dl given 6 units hai


O/E-

SYSTEMIC EXAMINATION -

CVS-S1, S2 +

 No Murmurs

RS-BAE+, crepts + in left infrascapular ,infra axillary areas

       

CNS- No focal Neurological deficit 

P/A - Soft ,Nontender


A-



70 yrs old Female with HOSPITAL ACQUIRED PNEUMONIA WITH TYPE 1RESPIRATORY FAILURE

WITH HYPERGLYCEMIA RESOLVED WITH CHOREA RESOLVED WITH DIABETIC NEPHROPATHY WITH REFURRENT UTI WITH IRON DEFICIENCY ANEMIA

K/C/O DM2 SINCE 30 YRS

K/C/I HYPOTHYROIDISM SINCE 15 YRS.

K/C/O CKD SINCE 2 YRS


P-


Head end elevation


Inj. Augmentin 1.2g/ iv / bd


T. Thyronorm 75 mcg po/od


T. Promet-xl 50 mg po/bd 


T. Tetrabenazine 12.5 mg po/tid


Inj. HAI s/c tid


8am- 8 units


1pm- 8 units


8pm- 8 units


Liquid paraffin for l/a bd


T. Teczine 5 mg po / sos


Nebulisation with budecort -12 th hourly

Mucomist -10 th hourly 


 Inj. Lasix 20 mg iv/bd


IVF- NS@50 ml /hr


Grbs monitoring


Input and output monitoring

15/02/23

ICU-BED NO. 2

UNIT 2


70 yrs old Female came with c/o generalised weakness since 1 week,

Involuntary movements of left upper limb since 1 week, cought with expectoration since 1 week


S

C/O COUGH WITH EXPECTORANTION DECREASED

STOOLS PASSED YESTERDAY 

NO FEVER SPIKES SINCE YESTERDAY NIGHT


O


PT IS C/C/C

TEMP-AFEBRILE

PR-78Bpm

SPO2-99% WITH 2L OF O2

BP-120/60mmhg

Grbs-

8 am -231 mg/dl

10 units hai given


O/E-

SYSTEMIC EXAMINATION -

CVS-S1, S2 PRESENT

 NO MURMURS

RS-BAE+, crepts + in left infrascapular ,infra axillary areas


CNS- No focal Neurological deficit 

P/A - Soft ,Nontender


Investigations -

S. Creatine-2. 8

Hb-7.8

TLC -15200

Neutrophils -75

Lymphocytes -12

Pcv-24.8

Mcv-58.9

Mch- 18.5

Mchc-31. 3

Rdw-16. 6

Platelet-2. 81

Na-134

K-3.8

Cl-102

Ca2+-1.11

Blood urea-102



A-



70 yrs old Female with HOSPITAL ACQUIRED PNEUMONIA WITH TYPE 1RESPIRATORY FAILURE( resolving)

WITH HYPERGLYCEMIA( RESOLVED )WITH CHOREA (RESOLVED) WITH DIABETIC NEPHROPATHY WITH REFURRENT UTI WITH IRON DEFICIENCY ANEMIA

K/C/O DM2 SINCE 30 YRS

K/C/I HYPOTHYROIDISM SINCE 15 YRS.

K/C/O CKD SINCE 2 YRS


P-


Head end elevation

IVF- NS@50 ml /hr

Inj. Augmentin 1.2g/ iv / bd-( day  2)

Inj. HAI s/c tid

8am- 8 units

1pm- 8 units

8pm- 8 units

T. Thyronorm 75 mcg po/od

T. Promet-xl 50 mg po/bd 

T. Tetrabenazine  12.5 mg po/tid

T. Teczine 5 mg po / sos

Liquid paraffin for l/a bd

Nebulisation with   budecort -12 th hourly

Mucomist -10 th hourly 

Grbs monitoring

Input and output monitoring




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