GENERAL MEDICINE CASE DISCUSSIONS
A 21 year old woman, hailing from Nalgonda, Telangana presented with the cheif complaints of
Vomiting since 4 days
Weakness in all her four limbs since 4pm since day before yesterday
Patient studied till 10th grade at Nalgonda government school. She was alright until 1 year back, after which she started finding it hard to control her urine, she started wetting her clothes frequently and her mother would always find her bed wet. She was brought to our hospital where in her mother was told that her right kidney was entirely damaged so they had to place a pipe into her left kidney. She had a gross right hydroureteronephrosis and a moderate left hydroureteronephrosis. A left nephrostomy was done for her along with bladder biopsy, she was on the drain for 6 months after which it was removed. Her bladder biopsy revealed granulomatous picture suspicious of TB.
The patient was diagnosed with Genitourinary TB and Thimble bladder. She was started on ATT and ureterosigmoidostomy was performed on On 10/11/2020. She completed her ATT for 6 months.
She was discharged on Tab Nodosis 1000mg per day initially. It was increased to 2500mg Nodosis per day.
Over the past one year, she says she has lost a significant amount of weight and she has been having loss of appetite since an year. She also tells that post surgery, she has experienced on and off low grade fever.
5 months post surgery, 5 days back, she started having Vomiting which were green in color, watery in consistency after consuming meals, 3-4 episodes per day for 3 days.
She was given antiemetics for her vomiting. 3 days later she started experiencing pain in both her lower limbs on walking even to her washroom. At this point she experienced no weakness.
At around 4pm that day, she suddenly found it difficult to get up from her bed. She found it difficult to lift her left lower limbs after around 20 minutes She developed weakness of her left upper limb. After 20 mins she developed weakness of right lower limb and right upper limb. She started finding it hard to hold her neck.
She however had no complaints of numbness or tingling in her limbs, no band like sensation, she was able to feel her clothes
She was able to urinate and pass bowel with no complaints. She had no complains of sweating, palpitations.
On presentation to us:
She was a thin built woman
PR - 72bpm
BP -
100/70mmhg in supine posture
90/70mmhg in standing posture
She had hypotonia in all her limbs.
Power in her all her limbs were 3/5
Reflexes were absent in her Triceps, biceps and supinators.
Her knee reflexes were 3+ with absent ankle reflex. Her plantars were mute.
Her touch, pain, temperature, joint position senses were intact but her vibration was 6 secs upto the ankle level.
10 secs in all the above joints.
Abg shows
PH was 7.217
Pco2 -26.6
Hco3 - 10.3
Po2 - 93.8
Showing metabolic acidosis with respiratory alkalosis
Anion gap of 23
Delta ratio of 0.8
And her potassium was 3.1
After potassium supplementation
Her power has improved to -4/5 in her lower limbs and +4/5 in upper limbs sir.
Her biceps, Triceps, supinators were 2+ today
Knees were 3+
Ankle reflex was absent
Plantars were flexion on the right side and mute on the left.
Mri spine turned out to be normal
But however they mentioned about a nodule in her left lung measuring 23mm.
INVESTIGATIONS:
On 20-9-21:
CHEST X-RAY:
At 3.00pm Pt.became tachypnoic with BP-100/60mm Hg,
RR- 32/min
PR- 142/min
Temp : 101°F
Spo2 : 84% on RA
RS : BAE (+) with B/L coarse crepts in ISA
Pt was drowsy but arousable
ABG showed (severe metabolic acidosis )
pH - 7.054
pCo2 - 9.7
pO2 - 93.4
Spo2- 93.1
HCo3(stat) - 6.2
HCo3 (c) - 2.6
Maintain Sp02 >90% by oxygen supplemention
INJ .LASIX 20mg/IV/ stat
INJ NEOMOL 1mg/ IV /stat
Pt landed in ? Acute heart failure secondary to myocardial depression.
We shifted her to icu and gave treatment.
After giving Lasix ,crepts disappeared and chest was clear on auscultation .
Her vitals were stable and spo2- was 98% with 4 lit oxygen.
We got ecg done which was showing st depressions in inferior and v3-v6 leads.
Echo was done and there was no RWMA.
Intubation notes
At 4 : 30 pm ,pt became unresponsive with PR - 186/min (ECG showing SVT with rate related ST Depression
With BP - 100/60 mm hg
Spo2 - 96% on RA
In v/o SVT INJ.DILTIAZEM 12.5 mg/IV /STAT
Inj.NaHCO3 100mEq /iv/stat slow given
Grbs : 56 mg/dl
IVF - 25% Dextrose given
PR - 86 /min rate again increased and reverted to SVT in 10 mins
Bp - 100/60 mm hg
Pr - 84 / min ,rate again increased and reverted to SVT in 10 mins(PR>180 )
BP : 100/40 mmHg
Inj.DILTIAZEM 25 mg /IV/STAT
Bp : 60 systolic
Spo2 : 95%on RA
PR: 86/min
Abg :
pH - 7.094
pCo2 - 31
PaO2 - 61
HCo3 - 9.2
In v/o gasping state with GCS - 3/15
With ABG showing type 1 respiratory failure .pt was intubated with ET -6.5 MM
after giving inj.vecuronium 4 mg ,inj.glycopyrolate 2cc/iv/stat and connected to mechanical ventilator acmv mode
RR=16/min. Acmu -ve
UT=380ml
PEEP : 5mm H2O
In v/o hypotension post intubation,
ABG showing
pH - 6.951
pCo2 - 49.2
pO2 - 379
SpO2 - 96.7%
HCo3(stat)- 9.1
HCo3(c)-10.3
Pt. was started on
Inj NORAD -DS@ 8ml/ hr
Inj.Dobutamine @ 4ml/ hr
Plan for thriple lumen catheter.
Due to severe metabolic acidosis she was tachypneic.
Due to severe metabolic acidosis she was tachypneic.
2 hours after intubation ,she expired due to ? Refractory acidosis.
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