75 year old with altered sensorium and adjustment disorder with AKI

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CASE :

75yrs old elderly man resident of Gorankapalli (Nalgonda dist) presented to our MOPD with the complaints of
Unable to get up from the bed since 3 days,
Difficulty in lifting head off from the pillows since 3 days,
Cough since 10 days,
Fever 10 days back 

Patient was apparently asymptomatic 3 years back

3 years back - He experienced a trauma to his head following slippage of his foot. A CT Brain was done which was normal.
1 year back - he got operated for inguinal hernia

On the 7th of this month his daughter  expired secondary to ? Pneumonia (covid) after this traumatic experience patient started feeling depressed, two days later he first noticed hiccups and the following which he developed low grade, intermittent fever not associated with chills and rigors, relieved on taking medications, along with dry cough for which he went to outside local hospital where he stayed for a night and received iv fluids with symptomatic managment and he got discharged the following day.

Since 3 days his son noticed that patient is unable to get up from the bed, difficulty in rolling over the bed, difficulty in lifting head off from the pillows and occasionally responding to commands and getting involved in conversations
He was unable to swallow when he is fed food and drink water
and attenders say that he is intermittently responding to them, not passing stools since 3 days

His son told us that his fever subsided however his cough did not.

No c/o vomitings, headache, nausea, pain abdomen, burning micturition, shortness of breath

He used to work as a farmer and is an occasional alcoholic. He used to smoke beedis 15 years back.

On examination,
Patient was drowsy, but arousable
Thin built
He has pallor
No icterus, cyanosis, clubbing, pedal edema, lymphadenopathy

VITALS 
Tempearture - 97.8 F
BP - 140/100 mmHg
PR - 86 bpm
RR - 17 cpm
SpO2 - 99% at room air
GRBS - 97 mg/dl

Respiratory system :
Bilateral air entry present,
Inspiratory crepts heard in bilateral IAA, ISA

CVS - S1 S2 heard
Per abdomen - Soft, non tender, BS present
CNS -
Reflexes :
                       Right              Left
Biceps -           3+                 3+
Triceps -           3+                 3+
Supinator -       2+                 2+
Knee -                -                     -
Ankle -               -                     -
Plantar -       extensor      extensor
      
Tone :
                            Right                  Left
    UL               Hypertonia       Hypertonia
    LL                  Normal             Normal

Power :
                         Right               Left
   UL                  3/5                  3/5
   LL                   2/5                  2/5

Sensory system couldn’t be ellicited

Neck stiffness - present
Kernigs sign absent

Provisional diagnosis :
Altered sensorium secondary to ? metabolic encephalopathy with adjustment disorder with AKI secondary to UTI

Investigations :

Hemogram :

Hb - 9 g/dl

RBC -  2.94 millions/cumm

TLC - 15,300 cells/cumm

Neutro - 86

Eosino - 1

Baso - 0

Lympho - 7 

Mono - 6

PLT - 2.63 lakhs/cumm

CUE

Acidic

Pus cells - plenty 

Albumin - +++

Sugar - nil 

Epithelial casts - 1-2 

RBC casts - 2-3 

LFT

Total bilirubin - 0.57 

Direct bilirubin - 0.12

AST - 10

ALT - 12

ALP - 170

Total protein - 5.3

Albumin - 2.7

A/G ratio - 1.06

RFT 

Sr. Urea - 71

Sr. Creatinine - 2.5

Sr. Na - 136

Sr. K - 4.1

Sr. Cl - 101

ABG 

pH - 7.4

pCO2 - 27.0

pO2 - 104

HCO3 - 18.9

St. HCO3 - 16.5

BT - 2 min 

CT - 4 min 30 sec 

ESR - 25 

RBS - 83 mg

Urinary electrolytes -

Sodium - 168

Potassium - 23.9

Chloride - 186

Urine protien/creatinine ratio -

Spot urine protein - 29 

Spot urine creatinine -  34.2

Ratio - 0.83

Sr. Calcium - 9.7

Serology ( HIV, HCV, HbsAg) - negative 

Dengue Serology - negative

Malaria parasite - negative

USG

Chest Xray PA view 

X ray C Spine

    Lateral view 

    AP view 

MRI BRAIN 

2 D echo 

ECG 

CSF analysis 

 Cell count - 1 

 Glucose - 66mg/dl

 Proteins - 15.7 mg/dl

 Chloride - 117 mmol/L

 

Fever charting:

Treatment:

Day 0

 - Lumbar puncture was done i/v/o suspected meningoencephalitis due to Altered sensorium and generalized weakness n and neck stiffness 

 CSF analysis showed

  Cell count - 1 

  Glucose - 66mg/dl

  Proteins - 15.7 mg/dl

  Chloride - 117 mmol/L

- INJ. CEFTRIAXONE 1GM/ IV/BD

- INJ. PAN 40 MG /IV/OD
- INJ. OPTINEURON 1amp in 100ml NS/IV/OD
- TAB. PCM 650mg PO/ SOS 

- NEU. with DUOLIN and BUDECORT 12th hourly 

- SYP. CREMAFFINE PLUS 15ML /PO/HS 

Day 1 

Subjective complaints -
C/o generalized weakness

Objective findings -
Temp - 98.4 F
BP - 140/80 mmhg
PR - 92 bpm
RR - 19 cpm
SpO2 - 99% at RA
GRBS - 101 g/dl
Input - 1100 ml
Output - 600 ml
CVS - S1 S2 heard 
RS - BAE present, basal creptitaions present 
Per Abdomen- soft, BS heard 

A-
Altered sensorium secondary to ? Metabolic encephalitis with adjustment disorder with AKI secondary to UTI

Investigations
Reticulocyte count - 0.4 

P -
- IV Fluids  2NS @75ml/hr
- INJ. CEFTRIAXONE 1GM/ IV/BD
- INJ. PAN 40 MG /IV/OD
- INJ. OPTINEURON 1amp in 100ml NS/IV/OD
- TAB. PCM 650mg PO/ SOS
- SYP. CREMAFFINE PLUS PO/ HS
- NEB. with DUOLIN and BUDECORT 8th hourly

Psychiatry referral was taken as patient had h/o traumatic experience of his daughter death after which he started feeling depressed, after evaluation they have diagnosed him with ADJUSTMENT DISORDER and DELIRIUM ( due to ? Metabolic or ? Sepsis - recovering ) and prescribed 

 - TAB. BUPRON XL 750 MG PO OD 

 - TAB. ADMENTA 10MG PO OD

Day 2 

Sensorium improved
C/o generalized weakness

Objective findings-
Temp - 98.5 F
BP - 140/100 mmhg
PR - 80 bpm
RR - 18 cpm
SpO2 - 99% at RA
GRBS - 116 g/dl
Input - 4200 ml
Output - 2400 ml
CVS - S1 S2 heard 
RS - BAE present, bilateral inspiratory crepts heard in IAS, ISS
Per Abdomen- soft, BS heard 

CNS                 
                       Right           Left

Reflexes B        3+             3+
                T        3+             3+
                S         +               +
                K         +               +
                A         +                +
                P      Withdrawal 

Assessment-
Altered sensorium secondary to ? Metabolic encephalitis with adjustment disorder with AKI secondary to UTI

Investigations
Urea - 71(D-0) - 82 (D-2)
Creat - 2.5(D-0) - 2 (D-2)
Hb - 9.5

TLC - 9800

RBC - 3.07

PLT - 2.68

Sr. Ferritin - 306

Plan of care -
- IV Fluids  2NS @75ml/hr
- INJ. CEFTRIAXONE 1GM/ IV/BD
- INJ. PAN 40 MG /IV/OD
- INJ. OPTINEURON 1amp in 100ml NS/IV/OD
- TAB. PCM 650mg PO/ SOS
- TAB. BUPRON XL 750mg PO OD
- TAB. ADMENTA 10mg PO OD
- SYP. CREMAFFINE PLUS PO/ HS
- NEB. with DUOLIN and BUDECORT 8th hourly

Day 3

S-
C/o Generalized weakness

O -
Temp - 98.5 F
BP - 110/80 mmhg
PR - 78 bpm
RR - 16 cpm
SpO2 - 99% at RA
GRBS - 102 g/dl
CVS - S1 S2 heard 
RS - BAE present
Per Abdomen- soft, BS heard 
CNS - HMF Intact

A-
Altered sensorium secondary to Metabolic encephalopathy with adjustment disorder with AKI secondary to UTI

Investigations
Urea- 71(D0) - 82 (D2) - 75(D3)
Creatinine - 2 (D0) - 2.5 (D2 ) - 2.4 (D3)

P -
- IV Fluids  2NS @75ml/hr
- INJ. CEFTRIAXONE 1GM/ IV/BD
- INJ. PAN 40 MG /IV/OD
- INJ. OPTINEURON 1amp in 100ml NS/IV/OD
- TAB. PCM 650mg PO/ SOS
- TAB. BUPRON XL 750mg PO OD
- TAB. ADMENTA 10mg PO OD
- NEB. with DUOLIN and BUDECORT 8th hourly

Day 4

S-
Sensorium improved, oriented to time, place and person.
Generalized weakness decreased

O -
Temp - 98.5 F
BP - 130/80 mmhg
PR - 82 bpm
RR - 18 cpm
SpO2 - 99% at RA
GRBS - 112 g/dl
CVS - S1 S2 heard 
RS - BAE present
Per Abdomen- soft, BS heard 
CNS - HMF Intact

A-
Altered sensorium secondary to Metabolic encephalopathy ( resolved ) with adjustment disorder with AKI secondary to UTI


P -
- Plenty of oral fluids
- TAB. TAXIM 200 MG / PO /BD
- TAB. PAN 40 MG PO/OD
- INJ. OPTINEURON 1amp in 100ml NS/IV/OD
- TAB. PCM 650mg PO/ SOS
- TAB. BUPRON XL 750mg PO OD
- TAB. ADMENTA 10mg PO OD
- NEB. with DUOLIN and BUDECORT and  MUCOMIST  8th hourly