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Here is a case i have seen:
A 51 year old female ,house wife came to the casuality with chief complaints of vomitings since ,20 days .
In 1994, she had twin pregnancy ,which was her second pregnancy , due to unknown cause one of the twin died intrauterine. Normal vaginal delivery
According to her sister she is got slightly depressed and was not a normal person since then .
In 2015,she was brought to here to gynaecology OP as,she had bleeding pervagina for 5 days,with h/o white discharge which is watery in consistency non foul smelling , not blood stained .
menstrual history - 10/20 ,heavy bleeding
obs history - P2L2
In 2019 , she had complaints of fever , got admitted in kamineni , for 1 month ,during which she also got referred to psychiatry as she could not recognise anyone which lasted for 5 days .
Patient was apparently asymptomatic 25days back then she developed fever , high grade ,progressive ,not associated with chills and rigors . for which she went to local RMP and is on fluids for 1 whole day.Next day she had vomitings ,( used to vomit everything after eating ,contents are food particles),again went to the RMP and got treated accordingly. As the condition didn’t regress she was admitted in the hospital for 1 week .after which she became normal .
After 4 days she again developed vomitings after eating (I.e 3/4 times a day)
Admitted in the hospital ,and on fluids for 2 days ,after which she came here for further treatment .
GENERAL EXAMINATION :
Pt is drowsy ,semi conscious,not cooperative during admission.
Bp 90/60 mmhg
PR- 98bpm
GRBS- 99mg/dl
RR -20cpm
CVS- s1s2 heard
RESP- BAE+
CNS -
sensory -can’t be elicited
motor—
power-can’t be elicited
Tone- normal
Reflexes -
GCS - E1V3M6
Patient got intubated due to cardiac arrest (was gasping ) at 1.00 am .she revivied after one cycle of CPR
Post intubation vitals -
BP - 120/60mmhg
PR - 75bpm
RR - 20 cpm
Spo2-90%.
GCS: E1VTM1
on CPAP vc mode for 7 hours
Fio2:100 RR : 22 I:E : 1:2 TV: 360 ml
R/S : B/L wheeze +
pt was now maintaining on T piece with 90 percent saturation
ECG on 22/12/20 .
ECG -23/12/20
INVESTIGATIONS-
22/12/20.
TREATMENT-
Day 1
inj cal gluconate 10 ml/10 percent in 100 ml ns iv /stat
inj 3 % Nacl @ 100/hr iv 117-119
inj noradrenaline 2 Amp in 50 ml Ns@ 14ml /hr
inj vasopressin 1 amp in 50 ml NS @1.6 ml/hr
RT feeding 1 hrly 30 ml + protein powder
50 ml of water hrly
IVF RL and DNS @ 50ml/hr
inj optineuron 1 amp in 109 ml ns iv bd
I/o charting
Day 2-
Inj 3 % NS @10ml/hr
inj NA 2amp in 50 ml NS 14ml/hr
inj vasopressin 1 amp in 50 ml NS @ 1.6 ml/hr
RT feeds 1 hrly 30ml milk + protein powder + 50 ml water hourly
serum sodium 4th hrly
i/o charting
IVF :RL,DNS @50ml/hr
inj optineuron 1 amp in 100 ml NS IV
Day3 ( 23/12/20)
O/E ,pupils - anisocoria RT>LT ,sluggish reactive to light on left.
dolls eye(+)
RESP- BAE+ ,coarse end crepts in Rt side in IMA,IAA
BP-not recordable (on inj noradrenaline 16ml/hr
vasopressin 2 ml/hr)
Treatment -
Head end elevation
RT feeds (50 ml water hourly , 100ml milk 2nd hourly )
suction every hourly
Inj pan 40mg/oD
inj NORAD DS@16ml/hr
inj vasopressin @2 ml/hr
inj monocef 1gm/IV/BD
inj NAHCO3 100meq IV/STAT
strict I/O charting hourly
GRBS 4th hourly
ABG 4th hourly
Refresh tears 4times
DIAGNOSIS- ??tubercular meningitis with right lung consolidation with dyselectrolytemia,with HFeEF with EF 43%,MVR sec to MV prolapse
with CAD -LAD territory (? STEMI) with severe metabolic acidosis .
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