Case 32 - 39M WITH ALTERED SENSORIUM AND B/L LOWER LIMB PARAPLEGIA WITH INVOLUNTARY MOVEMENTS OF UPPER LIMBS WITH BED SORES.

 

39M WITH ALTERED SENSORIUM AND B/L LOWER LIMB PARAPLEGIA WITH INVOLUNTARY MOVEMENTS OF UPPER LIMBS WITH BED SORES. November 10, 2021





A 39 Yr old male , electrician by occupation, with no significant medical history since childhood.
Chief complaints:-
**C/o decreased responsiveness since 2 days
**Not eating since 2 days 
**Decreased speech since 2 days--completely not talking since today morning.

Past illness:-

**8 months ago -- c/o low back ache , pain abdomen -- was told to have renal stones , meatal stenosis--underwent urethral dilatation in July 2021.
** 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 , used unani medication.
**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 6 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.

Personal history:-

** He has normal appetite , unmarried, mixed vegitation with regular bowel movements, he was on Foley's since 6 months .
No addictions.

ON EXAMINATION:-

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 
2) SECONDARY TO? POST ICTAL CONFUSION WITH ? ACUTE ISCHEMIC CVA( PARIETO TEMPORAL AREA) 
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--NEGATIVEp
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


S- patient in altered sensorium .
Tremors of both upper limbs -? Uremic tremors 

O - GCS - E4V1M4
      Temp-99 degrees F
     PR-130/min 
     Bp-100/80mmHg

CNS - pupils - NSRL
Tone - hypertonia in upper limbs .
Hypo in lower limbs 
Power -upper limb -3/5( resistance couldn't be tested because of altered sensorium ) 

lower limb -0/5 
  
Reflexes - rt.         Lft 
        B.        +3       +3
       T.         +3.        +3 
        P      mute        mute
        K.        -.             - 
        A.      -.              - 
       
No meningeal signs . 

A - Altered sensorium secondary to uremic encephalopathy
Uremic tremors .
Focal seizure with secondary generalization
Paraplegia - secondary to Potts spine .
Anemia - ? Anemia of chronic inflammation
Grade 4 bed sore .
CKD V- with severe metabolic acidosis
Old lacunar infarct in Right caudate nucleus
Left lower limb DVT 

Plan - 
1)Iv fluids -1 NS @75 ml/hr
2)Ryles tube feeds(milk+protein powder;water) - 4th hrly .
3)ATT 
4)INJ OPTINEURON 1 AMP IN 100ML NS/IV/OD
5)INJ.LEVIPIL 500 MG IV/BD
6)INJ.CEFTRIAXONE 1 GM/IV/BD
7)INJ.CLINDAMYCIN 600 MG/IV/TID
8)INJ NOR-AD DS-2 AMP IN 50ML NS IV @6ML/HR
9)INJ.PAN 40 MG IV/OD
10)INJ.NEOMOL 1GM IV/SOS IF TEMP >102
11)INJ.ZOFER 4 MG IV/TID
12)INJ.LEVOFLOXACIN 750 MG IV
13)GRBS 8TH HOURLY
14)BP/PR/TEMP MONITORING 2ND HRLY
15)DVT STOCKINGS 

Pt underwent Doppler yesterday-thrombus present
Should we start him on clexane 40 mg bd, but his platelet count is-50k.












S- patient is in altered sensorium .
 
O - GCS - E4V1M4
      Temp-99 degrees F
     PR-130/min 
     Bp-100/80mmHg with NA 18 ml/hr
Tremors of both upper limbs -? Uremic tremors reduced 
CNS - pupils - NSRL
Tone - hypertonia in upper limbs .
Hypo in lower limbs 
Power -upper limb -3/5( resistance couldn't be tested because of altered sensorium ) 

lower limb -0/5 
  
Reflexes - rt.         Lft 
        B.        +3       +3
       T.         +3.        +3 
        P      mute        mute
        K.        -.             - 
        A.      -.              - 
       
No meningeal signs . 

A - Altered sensorium secondary to uremic encephalopathy
Uremic tremors .
Focal seizure with secondary generalization
Paraplegia - secondary to Potts spine .
Anemia - ? Anemia of chronic inflammation
Grade 4 bed sore .
CKD V- with severe metabolic acidosis
Old lacunar infarct in Right caudate nucleus
Left lower limb DVT 

Plan - 
1)Iv fluids -1 NS @75 ml/hr
2)Ryles tube feeds(milk+protein powder;water) - 4th hrly .
3)ATT 
4)INJ OPTINEURON 1 AMP IN 100ML NS/IV/OD
5)INJ.LEVIPIL 500 MG IV/BD
6)INJ.CEFTRIAXONE 1 GM/IV/BD
7)INJ.CLINDAMYCIN 600 MG/IV/TID
8)INJ NOR-AD DS-2 AMP IN 50ML NS IV @6ML/HR
9)INJ.PAN 40 MG IV/OD
10)INJ.NEOMOL 1GM IV/SOS IF TEMP >102
11)INJ.ZOFER 4 MG IV/TID
12)INJ.LEVOFLOXACIN 750 MG IV
13)GRBS 8TH HOURLY
14)BP/PR/TEMP MONITORING 2ND HRLY
15)DVT STOCKINGS 

1 session of dialysis done yesterday along with one PRBC transfusion




S- 
patient is conscious , obeying verbal commands,making sounds ,but unable to speak

 
O -
 GCS -E4V2M4
 Temp-99.2 degrees F
  PR-132/min 
  Bp-90/60mmHg with NA 18 ml/hr
Tremors of both upper limbs -? Uremic tremors reduced 
CNS - pupils - NSRL
Tone - hypertonia in upper limbs .
Hypo in lower limbs 
Power -upper limb -3/5( resistance couldn't be tested because of altered sensorium ) 

lower limb -0/5 
  
Reflexes - rt.         Lft 
        B.        +3       +3
       T.         +3.        +3 
        P      mute        mute
        K.        -.             - 
        A.      -.              - 
       
No meningeal signs . 

A - Altered sensorium secondary to uremic encephalopathy
Uremic tremors .
Focal seizure with secondary generalization
Paraplegia - secondary to Potts spine .
Anemia - ? Anemia of chronic inflammation
Grade 4 bed sore .
CKD V- with severe metabolic acidosis
Old lacunar infarct in Right caudate nucleus
Left lower limb DVT 

Plan - 
1)Iv fluids -1 NS @75 ml/hr
2)Ryles tube feeds(milk+protein powder;water) - 4th hrly .
3)ATT 
4)INJ OPTINEURON 1 AMP IN 100ML NS/IV/OD
5)INJ.LEVIPIL 500 MG IV/BD
6)INJ.CEFTRIAXONE 1 GM/IV/BD
7)INJ.CLINDAMYCIN 600 MG/IV/TID
8)INJ NOR-AD DS-2 AMP IN 50ML NS IV @6ML/HR
9)INJ.PAN 40 MG IV/OD
10)INJ.NEOMOL 1GM IV/SOS IF TEMP >102
11)INJ.ZOFER 4 MG IV/TID
12)GRBS 8TH HOURLY
13)BP/PR/TEMP MONITORING 2ND HRLY
14)DVT STOCKINGS 

1 session of dialysis done day before yesterday along with one PRBC transfusion


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