ALTERED SENSORIUM SECONDARY TO SEPTIC ENCEPHALOPATHY ?UREMIC ENCEPHALOPATHY(RESOLVING)HYPOGLYCEMIA(RESOLVED) WITH ULCER OVER ANTERIOR ASPECT OF LOWER LIMB SECONDARY TO FILARIASIS WITH AKI(PRE RENAL)WITH K/C/O HTN SINCE 10 YRS,K/C/O CAD SINCE 2 YRS S/P : 5 SESSIONS OF HAEMODIALYSIS DONE

Case History and Clinical Findings 
PATIENT WAS BROUGHT TO CASUALTY WITH COMPLAINTS OF PAIN ABDOMEN SINCE 4 DAYS AND SWELLING OF LEFT LOWER LIMB SINCE 4 DAYS 
HOPI: 
PATIENT WAS APPARENTLY ASYMPTOMATIC 4 DAYS AGO THEN SHE DEVELOPED PAIN ABDOMEN WHICH IS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE. NO AGGRAVATING AND RELEIVING FACTORS. SQUEEZING TYPE OF PAIN PRESENT. H/O FEVER CONTINUOUS TYPE AND RELEIVED ON MEDICATION H/O ANOREXIA,NAUSEA PRESENT NO H/O VOMITINGS H/O ITCHING PRESENT OVER LEFT LEG 5 DAYS AGO K/C/O HTN AND ON REGULAR MEDICATIONN/K/C/O TB,ASTHMA,DM,CVA,CAD,THYROID DISORDERS,EPILEPSY
PERSONAL HISTORY:APPETITE IS NORMALDIET IS MIXEDSLEEP ADEQUATEBOWEL AND BLADDER REGULARADDICTIONS- NO
FAMILY HISTORY: NO RELAVANT FAMILY HISTORY
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS, COHERENT,COOPERATIVE.MODERATELY BUILT AND NOURISHEDNO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS,LYMPHEDENOPATHY,
VITALS:TEMP: 98.6FPR: 78BPMBP: 130/90MMHGRR: 18CPM
CVS: S1S2 HEARDRS: BAE+
P/A: SOFT AND NON TENDER
COURSE IN THE HOSPITAL:
PATIENT WAS BROUGHT TO CASUALTY WITH C/O PAIN ABDOMEN SINCE 4 DAYS AND SWELLINJG OF LEFT LOWER LIMB SINCE 4 DAYS AND WAS ADMITTED UNDER GS AND GM REFERAL WAS DONE I/V/O FEVER,B/L PITTING EDEMA OF LL AND CASE VHAS BEEN TAKEN OVER BY GM DEPARTMENT I/V/O ALTERED SENSORIUM ON 4 /9/23 AND AWS DIAGNOSED TO HAVE ALTERED SENSORIUM SECONDARY TO ? HYPOGLYCEMIA(RESOLVED) ?SEPTIC ENCEPHALOPATHY ?UREMIC ENCEPHALOPATHY WITH ULCER OVER ANTERIOR ASPECT OF LEFT LL SECONDARY TO FILARIASIS WITH K/C/O HTN AND CADNEPHROLOGY OPINION WAS TAKEN ON 4/9/23 I/V/O RAISED SERUM UREA AND CREATININE AND WAS ADVISED TO START ON DIALYSIS I/V/O UREMIC ENCEPHALOPATHY AND ANURIAAFTER 2 SESSIONS OF HEMODIALYSIS PATIENT RECOVERED FROM ALTERED SENSORIUM AND A TOTAL OF 5 SESSIONS OF HEMODIALYSIS HAVE BEEN DONE. MEANWHILE PATIENT WAS TREATED WITH IV ANTIBIOTICS I/V/O SEPSIS AND GRADUALLY RECOVERED.PATIENT IS IN HEMODYNAMICALLY STABLE CONDIDTION AT THE TIME OF DISCHARGEUREA TREND DURING HER COURSE IN THE HOSPITAL:152-->154->110-->68-->58-->61-->54-->58-->65-->70
 Investigation 
COMPLETE BLOOD PICTURE (CBP) 03-09-2023 03:08:PM HAEMOGLOBIN 9.7 gm/dl15.0-12.0 gm/dl TOTAL COUNT 28700 cells/cumm10000-4000 cells/cumm NEUTROPHILS 95 %80-40 % LYMPHOCYTES 03 %40-20 % EOSINOPHILS 01 %6-1 % MONOCYTES 02 %10-2 %BASOPHILS 00 %2-0 % PLATELET COUNT 1.94 SMEAR Normocytic normochromic anemia with neutrophilic leucocytosis SERUM CREATININE03-09-2023 04:25:PM 4.4 mg/dl1.2-0.6 mg/dl LIVER FUNCTION TEST (LFT) 04-09-2023 03:06:AM Total Bilurubin 1.34 mg/dl1-0 mg/dl Direct Bilurubin 0.81 mg/dl0.2-0.0 mg/dl SGOT(AST) 307 IU/L31-0 IU/L SGPT(ALT) 89 IU/L34-0 IU/L ALKALINE PHOSPHATE 308 IU/L141-53 IU/L TOTAL PROTEINS 4.8 gm/dl8.3-6.4 gm/dl ALBUMIN 2.2 gm/dl4.6-3.2 gm/dl A/G RATIO 0.84 COMPLETE URINE EXAMINATION (CUE) 04-09-2023 04:21:AM COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010ALBUMIN +++ SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 2-3 EPITHELIAL CELLS 4-5 RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil LIVER FUNCTION TEST (LFT) 05-09-2023 05:53:AM 
Total Bilurubin 1.65 mg/dl1-0 mg/dl Direct Bilurubin 0.60 mg/dl0.2-0.0 mg/dl SGOT(AST) 203 IU/L31-0 IU/L SGPT(ALT) 69 IU/L34-0 IU/L ALKALINE PHOSPHATE 392 IU/L141-53 IU/L TOTAL PROTEINS7.0 gm/dl8.3-6.4 gm/dl ALBUMIN 3.5 gm/dl4.6-3.2 gm/dl A/G RATIO 1.0 ABG 06-09-2023 08:58:PM PH 7.36 PCO2 42.8 PO2 67.7 HCO3 23.6 St.HCO3 23.2 BEB-1.3 BEecf-1.1 TCO2 48.3 O2 Sat 93.7 O2 Count 15.8 BLOOD UREA07-09-2023 05:54:AM 58 mg/dl50-17 mg/dl SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 07-09-2023 05:54:AM SODIUM 136 mEq/L145-136 mEq/L POTASSIUM 3.4 mEq/L5.1-3.5 mEq/L CHLORIDE98 mEq/L98-107 mEq/L CALCIUM IONIZED 0.96 mmol/Lmmol/L BLOOD UREA08-09-2023 04:38:AM 61 mg/dl50-17 mg/dl SERUM CREATININE09-09-2023 05:09:AM 2.3 mg/dl1.2-0.6 mg/dl BLOOD UREA09-09-2023 11:59:PM 58 mg/dl50-17 mg/dl SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 09-09-2023 11:59:PM SODIUM 132 mEq/L145-136 mEq/L POTASSIUM 3.9 mEq/L5.1-3.5 mEq/L CHLORIDE 98 mEq/L98-107 mEq/L CALCIUM IONIZED 1.12 mmol/Lmmol/L SERUM CREATININE11-09-2023 05:57:AM 3.0 mg/dl1.2-0.6 mg/dl BLOOD UREA11-09-2023 11:54:PM 70 mg/dl50-17 mg/dl SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 11-09-2023 11:54:PM SODIUM 132 mEq/L145-136 mEq/L POTASSIUM 4.1 mEq/L5.1-3.5 mEq/L CHLORIDE 98 mEq/L98-107 mEq/L CALCIUM IONIZED 1.10 mmol/Lmmol/L SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 03-09-2023 03:55:PM SODIUM139 mEq/L145-136 mEq/L POTASSIUM 3.2 mEq/L5.1-3.5 mEq/L CHLORIDE 106 mEq/L98-107 mEq/L CALCIUM IONIZED 0.88 mmol/Lmmol/L BLOOD UREA04-09-2023 03:06:AM 152 mg/dl50-17 mg/dl RFT 04-09-2023 04:21:AM UREA 154 mg/dl50-17 mg/dl CREATININE 5.1 mg/dl1.2-0.6 mg/dl URIC ACID 9.9 mg/dl6-2.6 mg/dl CALCIUM 7.5 mg/dl10.2-8.6 mg/dl PHOSPHOROUS 5.5 mg/dl4.5-2.5 mg/dl SODIUM 142 mEq/L145-136 mEq/L POTASSIUM 3.7 mEq/L5.1-3.5 mEq/L CHLORIDE 99 mEq/L98-107 mEq/L RFT 05-09-2023 05:53:AM UREA 110 mg/dl50-17 mg/dl CREATININE 3.4 mg/dl1.2-0.6 mg/dl URIC ACID 8.4 mg/dl6-2.6 mg/dl CALCIUM7.9 mg/dl10.2-8.6 mg/dl PHOSPHOROUS 5.0 mg/dl4.5-2.5 mg/dl SODIUM 139 mEq/L145-136 mEq/L POTASSIUM 3.7 mEq/L5.1-3.5 mEq/L CHLORIDE 99 mEq/L98-107 mEq/L RFT 06-09-2023 05:21:AM UREA 68 mg/dl50-17 mg/dl UREA 28 mg/dl50-17 mg/dl CREATININE 2.3 mg/dl1.2-0.6 mg/dl CREATININE 2.8 mg/dl1.2-0.6 mg/dl URIC ACID 3.2 mg/dl6-2.6 mg/dl URIC ACID 3.2 mg/dl6-2.6 mg/dl CALCIUM 9.6 mg/dl10.2-8.6 mg/dl CALCIUM 9.6 mg/dl10.2-8.6 mg/dl PHOSPHOROUS 2.5 mg/dl4.5-2.5 mg/dl PHOSPHOROUS 2.5 mg/dl4.5-2.5 mg/dl SODIUM 138 mEq/L145-136 mEq/L SODIUM 138 mEq/L145-136 mEq/LPOTASSIUM 3.5 mEq/L5.1-3.5 mEq/L POTASSIUM 3.5 mEq/L5.1-3.5 mEq/L CHLORIDE 98 mEq/L98-107 mEq/L CHLORIDE 98 mEq/L98-107 mEq/L SERUM CREATININE07-09-2023 05:54:AM 2.3 mg/dl1.2-0.6 mg/dl ABG 08-09-2023 04:38:AM PH 7.36 PCO2 41.6 PO2 73.8 HCO3 23.0 St.HCO3 22.9 BEB-1.8 BEecf-1.7 TCO2 48.0 O2 Sat 95.0 O2 Count 13.7 SERUM CREATININE08-09-2023 04:38:AM 2.6 mg/dl1.2-0.6 mg/dlBLOOD UREA09-09-2023 05:09:AM 54 mg/dl50-17 mg/dl SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 09-09-2023 05:09:AM SODIUM 131 mEq/L145-136 mEq/L POTASSIUM 3.6 mEq/L5.1-3.5 mEq/L CHLORIDE 96 mEq/L98-107 mEq/L CALCIUM IONIZED 0.94 mmol/Lmmol/L SERUM CREATININE09-09-2023 11:59:PM 3.0 mg/dl1.2-0.6 mg/dl BLOOD UREA11-09-2023 05:57:AM 65 mg/dl50-17 mg/dl SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 11-09-2023 05:57:AM SODIUM 129 mEq/L145-136 mEq/L POTASSIUM 4.2 mEq/L5.1-3.5 mEq/L CHLORIDE 97 mEq/L98-107 mEq/L CALCIUM IONIZED 1.16 mmol/Lmmol/L SERUM CREATININE11-09-2023 11:54:PM 4.2 mg/dl1.2-0.6 mg/dl CBP : 3/9/23 4/9/23 5/9/23 6/9/23 7/9/23 8/9/23 9/9/23 10/9 11/9 12/9 HB: 9.7 9.3 9.1 9.6 9.4 9.1 9.1 8.9 8.4 7.9 TLC: 28700 30000 28000 20400 21000 23200 21300 19100 17700 37500 PLT: 1.94 1.6 1.5 1.0 1.1 1.2 1.3 1.5 1.65 1.5 2D ECHO: EF: 65%MILD AR+ ,MODERATE TR+ WITH PAH,NO MR NO RWMA, NO AS/MS,SCLEROTIC AV GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION +, NO PE USG: GRADE II FATTY LIVER RIGHT KIDNEY: 9.6 X 4.8 CM NORMAL S/E CMD + LEFT KIDNEY : 11.2 X 5.1 CM NORMAL S/E CMD +
Diagnosis
 ALTERED SENSORIUM SECONDARY TO SEPTIC ENCEPHALOPATHY ?UREMIC ENCEPHALOPATHY(RESOLVING)HYPOGLYCEMIA(RESOLVED) WITH ULCER OVER ANTERIOR ASPECT OF LOWER LIMB SECONDARY TO FILARIASIS WITH AKI(PRE RENAL)WITH K/C/O HTN SINCE 10 YRS,K/C/O CAD SINCE 2 YRS S/P : 5 SESSIONS OF HAEMODIALYSIS DONE 
 Treatment Given
1. INJ LEVOFLOXACIN 750 MG IV/OD 
2. INJ AUGMENTIN 1.2 GM IV/BD 
3. T. DEC 100 MG PO/BD
 4. T. ECOSPRIN AV 75/10 PO/HS 
5. GRBS MONITORING 4TH HOURLY
 6. T. OROFER XT PO /OD 
7. T. LASIX 40 MG PO/TID 
8. INJ BUSCOPAN IV/BD
 9. INJ PIPTAZ IV /TID FOR 7 DAYS
 Advice at Discharge
 1. TAB LEVOFLOXACIN 750 MG PO/BD X 5 DAYS 2. TAB AUGMENTIN 625 MG PO/BD X 5 DAYS 3. T. DEC 100 MG PO/BD X 5 DAYS 4. T. ECOSPRIN AV 75/10 PO/HS X 5 DAYS 5.T. OROFER XT PO /OD X 5 DAYS 6. T. LASIX 40 MG PO/TID X 3 DAYS

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