medicine posting (log 1)

Hello everyone.. I am Aditya Rayilla, an intern posted in medicine department and one of the important terms of getting the internship completion is to complete my log book with my online log of what I learn during the course of my duties. 

I'd mainly like to discuss about two patients that were admitted under our unit last week.

1. A 65 year old female who presented with Acute gastroenteritis and had hypovolemic shock with metabolic acidosis at the time of admission. Interestingly she is also a k/c/o Right sided hemiparesis.

2. An 18 year old quadriparesis patient who is now diagnosed with sensory motor axonal neuropathy after NCV. (Whose complete and detailed blog will shortly be uploaded by another co-intern) 

https://sowmyamutyala.blogspot.com/2020/05/hello-everyone.html

This link provides the case presentation (1) in a detailed and great way. Made by our coleagye intern Dr.M.Sowmya. 

I'd like to discuss more about the progress of this patient rather than the case as it has already been posted. It is important to note that the blog on this patient is being shared as an experience of what I had learnt during a night duty in ICU rather than as a case presentation. 

On the day of admission she came in with altered sensorium due to metabolic acidosis, the cause of this acidosis was probably acute gastroenteritis from which she was suffering from. Acute gastroenteritis caused a loss of H2O along with bicarbonate (HCO3 minus ions) from the serum which lead to the fall of the patients pH to 7.09 at the time of presentation. Along with Acute gastroenteritis she presented with Acute kidney injury, however it is most likely that this AKI is secondary to acute gastroenteritis, here is a link to an article  that shows that aki might be linked to gastroenteritis due gastrointestinal volume depletion in most of the cases. This volume depletion causes hypovolemic shock which in turn causes a decrease in GFR which ultimately causes AKI.

 

(((((https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.ijss-sn.com/uploads/2/0/1/5/20153321/ijss_nov_oa11_-_2016.pdf&ved=2ahUKEwickf-0_NvpAhVtzjgGHUnSBewQFjALegQIAhAB&usg=AOvVaw1ppR4qyjbExaIEZeYi_A3R&cshid=1590855109548))))))

Coming to the case, she was barely conscious and there was poor tone of both upper limb and lower limb muscles. However after the abg came in she was given Bicarbs as acidosis was confirmed, she was suffering from hypovolemic shock as mentioned, usually in a case like this they'd be put on extensive I.V fluids but here hemoglobin levels were low (6.9) in which case if we'd have given extensive fluid therapy another set of problems would have arised like heart failure, it was very captivating that our post graduate had waited for the heamoglobin levels and closely monitored the fluid therapy instead of starting an extensive ivf for her as this could cause heart failure due to her aneamic condition. She was put on 20% NS 20ml/kg bodyweight (she has a very low BMI). She had a very low urine output which eventually got better after the fluid therapy. 

This could have been an AKI super imposing on a previous chronic renal disease as Bun/creat is less than 10 and the anemia looked chronic in nature.

But as identified by our P.G Dr. Rashmitha ma'm 

Usg findings show normal kidney size and echogenicity.

Initially 3-4 months back her base line creatinine was 1.5.

This gave us a thought that renal aki outweighs ckd, Most probably.

And the anemia shows rbc indices suggesting of microcytic hypochromia.( ckd usually shows normocytic) but however, 

BUN/creat more than 15 usually suggests AKI. In AKI, urea shoots up way more than creat. 

And as said by Dr. Bhavik Shah In CRF, most of the times, he had seen microcytic hypochromic picture rather than the textbook described normocytic picture due to the Indian scenerio. 

Ultimately we couldn't judge if It was an AKI or a chronic renal issue. 

Coming to the limb weakness she is a k/c/o Rt sided hemiparesis with left sided parietal infarct, however on examination we also found that the left nasolabial fold was more significant than the right side nasolabial fold (picture in the link below) and since there was no involvement of the other parts of the face on right side we thought it might be an UMN type of 7th nerve palsy. 

After the treatment (mentioned in detail in the blog of Dr. Sowmya) she was feeling better and was in a position to walk, (remember she was barely conscious 16 hours ago in an altered sensorium state of mind). Her pH was increased to 7.37 from 7.09 which made her electrolytes more stable. Her gastroenteritis has resolved significantly as mentioned in the blog, and she has regained power on both the sides but her right hemiparesis still persists and limits her regain of power to this side. 

NOW.                                      At admission

Pt c/c.                              -Altered sensorium

BP- 100/60.                     50/40mmhg

CNS examination as of today shows that she's regaining the power a little bit assymetrically due to hemiparesis but since she's able to show muscle activity against resistance and gravity we have labeled her 4/5 and even the reflexes are a little assymetrical in nature.. the videos are posted in the previous blog by (Dr. Sowmya)

                  Right.       Left

Tone: 

UL.                 N              N

LL.                 N             N

Power:

UL.              4/5.         4/5

LL.               4/5.         4/5

Reflexes:       

Biceps.           ++           +++

Triceps.          ++           +++

Supinator.      ++          +++

Knee.              ++           +++

Ankle.             ++           ++

Plantar.           E              F

Her treatment as of today: 

1. T. Ecospirin 75mg/OD

2. T. Atorvas 20mg/ h/s 

3. T. Orofer XT /BD

4. Bp, PR, RR charting 

5. strict I/O charting

6. GRBS charting 12 hourly 

7. Plenty of oral fluids

Coming to the end of today's blog,

It is fascinating to see that on our last o.p day (26/05/20) we had easily seen around 6 cases of limb weakness (mostly hemiparesis and quadriparesis) from around the same region, but of different age group. Which might be an indicative of something that might be going on this region. 

 Out of these cases an 18 year old male patient was admitted under our unit, his detailed blog will shortly be uploaded by our colleague Dr. Priyanka (GM unit 2 intern) this individual told that it was sudden in onset but after the neurologists consultation in our hospital it was noticed that the onset would've probably been gradual but the notification of the weakness usually by the patient would probably be of sudden origin as the history didn't show any signs of sudden cause of quadriparesis such as trauma/stroke/ICB (happens frequently), he was clinically diagnosed to be GBS after ruling out other differentials during the neurology consultation 

After the nerve conduction velocity (NCV) study done today the report showed severe sensory motor axonal neuropathy. His details and case presentation will be uploaded shortly. 

It is important to point out that Because of the global pandemic we haven't been able to look at alot of cases but this methology of e-blogs and daily case discussions helps us look at the the few cases we have, in a more detailed way and helps us learn more from the less resources we have right now. 

Thank you.