BALIOSPERUUM462MONTANUM(MR) Patient summary in two drafts

First Draft from paper file:

FINAL DIAGNOSIS:

Disseminated  tuberculosis  with  sepsis , Acute rental  failure with sever metabolic acidosis  with

Cervical spinal tuberculosis with diabetic mallities.

HISTORY:

Patient came to causality with chief complain of dull and drowsy behavior. Loss of Appetite ,after taking

Vitals  are very poor so patient was shifted  to MICU and was ventilated .After taking brief history from patient wife there was past history of T.B and patient was started with ATT . But patient got allergic to

It with presentation of mouth ulcers and exfoliation of skin.

                Patient ABG , KFT , LFT , CBC  , After  getting the report patient  was anemic with urea and Creates raised and metabolic acidosis. With RBS of 512 so diagnosis of DK with raised ketons . So

Patient was started on injection  dextrose . Kpotecium chloride , sodium bicarbonate and monited hourly .On taking  chest x-ray ,  cavitery  lesion was started after consulting Tuberculosis

Physician , ATT was again started with DOTS Instruction . with proper monitoring

On 25 / 05 / 2016 patient became dyspnic , unconscious  , tachyphoea , vitals becoming  poor and

CPR  was given patient was not responding and was declare dead on 26/05/2016 at 06:26 Am

PHYSICAL EXAMINATION :

G.C => Gravely poor

H.R => 30/M

B/P => N/R

RESPIRATION => GASPING

PULSE =>N/R

PUPIL => F/D

INVESTIGATION  WITH REPORT :-

CBC  =>H.B – 8.8

              TLC – 13,200

              P  -  84

              L  -  13

              M – 01

              E –  02

              B  - 0

              PLAT  - 1.78 LAC

KFT  => U – 62 

              CR – 3.2

              NA+ - 165

              K – 4.5

              CL – 116

CVP => 4 CM (4 A.M)

              7.5 CM (10 P.M )

2nd DRAFT:

after going through the online record here: http://udhc161.blogspot.in/2016/05/baliosperuum462montanummra-43-year-old.html?m=1

and patient centered conversational clinical decision support on social media here: http://userdrivenhealthcare.blogspot.in/2016/06/baliosperuum462montanummr.html

FINAL DIAGNOSIS:

Disseminated  tuberculosis  with  sepsis , Acute rental  failure with severe metabolic acidosis  with

Cervical spinal tuberculosis on ATT and Steven Johnson’s syndrome

Diabetes Mellitus.

HISTORY:

The patient had a history of sudden left hemi-paresis 13 years back after a severe chest pain episode.

5 years back the patient noticed weight loss and was diagnosed to have diabetes.

In the recent past 2 months back the patient had neck pains and was diagnosed to have cervical T.B for which the patient was started on anti-tubercular therapy ATT but the patient developed mouth ulcers and exfoliation of skin after 4 weeks of ATT which was labeled as Steven Johnshon’s syndrome.

Patient came to casualty on the morning of May 16^th with a chief complaint of dull and drowsy behavior. 

PHYSICAL EXAMINATION :

During admission:

 Drowsy comatose

Acidotic breathing

Right hemiparesis due to cervical spinal TB

INVESTIGATIONS :-

CBC- 16^th May WBC-18,300

CBC  24^th May=>H.B – 8. TLC – 13,200

CBC 25^th May 29,300

KFT  24^th May=> Urea – 62  creatinine – 3.2, NA+ - 16,  K – 4.5 , CL – 116

CVP => 4 CM (4 A.M), 7.5 CM (10 P.M )

DETAILS OF TREATMENT:-

On admission, Patient ‘s ABG , KFT , LFT , CBC  revealed anemia with acute renal failure and severe metabolic acidosis along with hyperglycemia with an initial random blood sugar RBS of 512 for which patient was treated with IV fluids as per CVP and Insulin as per an algorithm. His drowsiness subsided the day after and by May 21 he was subjectively much better and eating well (objectively his WBC counts were down to 13,700 on May 21 from initial counts of 18,300 on May 16th).

A recent CXR pa view taken in the ICU revealed extensive pulmonary TB for which ATT that was stopped was re-started  with re-introduction of single drug INH in the HRZE-DOTS combination.

 He was planned to be shifted to casualty by May 23 but on the evening of May 24 worsening of symptoms in the form of recurrence of acidotic breathing and severe acidosis in the ABG was noted.

We searched for potential causes and considered INH toxicity although later we found his WBC counts had also gone up drastically from 13,200 on the morning of 24^th may to 29,300 on the morning of 25^th May and attributed his worsening to sepsis and although we escalated the antibiotics we realized this may have been a mycobacterial  sepsis.

At the night of 25 / 05 / 2016 patient became further dyspnoeic  with acidotic breathing as well as drowsy and comatose and on the early hours of 26/05/2016 at 06:26 AM he suffered a cardiac arrest from which he couldn’t be revived. 

CAUSE OF DEATH (FOR NON  MLC):-

Immediate cause: Disseminated T.B sepsis with severe metabolic acidosis and acute renal failure

Antecedent cause: Cervical spine T.B with DM