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:

On 21-9-21

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.

2 hours after intubation ,she expired  due to ? Refractory acidosis.