64 F altered sensorium, CKD on MHD, HFREF, Septic arthritis

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Here we discuss our patient problems through a series of inputs from the available Global online community of experts with n aim to solve those patient clinical problems with the current best evidence-based input

This Blog also reflects my patient-centred online learning portfolio.

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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competence in reading and comprehending clinical data including history, clinical findings, and investigations and coming up with a diagnosis and treatment plan.

CONSENT AND DEIDENTIFICATION : 

The patient and the attendees have been adequately informed about this documentation and the privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

PRESENTING COMPLAINTS:

A 64 year female, home maker, resident of Chinnasuraram, Nalgonda; brought to casuality with complaints of

Breathlessness since 20days.

Decreased Urinary output since 10 days.

Fever since 5 days.

HOPI:

Patient was apparently asymptomatic 4 years ago, after the demise of her husband (due to renal issues - due to breathlessness; he was chronic smoker and alcoholic); she was feeling low and continued to look after her grandchildren at home, and does household works. She started taking pain killers twice daily and sometimes injections since 2 years due to body pains. On 2nd may, after the demise of her grandson; she constantly feeling low and not taking food properly, took only small quantity of fluids (milk and water). Her relatives noticed swelling of both lower limbs till ankle. Since 20 days she had complaints of Breathlessness while walking and unable to perform her routine activities which has progressed to breathlessness at rest since last 6 to 7 days. (as per the attendees, patient was having such episodes of breathlessness since an year, which was informed to attendees multiplr times on phonecall, which was neglected by the attendees, as they were living away from home to gain their livelihood). Decrease in urinary output since 10 days. She had complaints of fever since 5 days, associated with chills and rigors.

PAST HISTORY:

Hypertensive on unknown medication since 6 months.

PERSONAL HISTORY:

Appetite decreased.

Bowel movements regular.

Decreased urinary output.

No known allergic history.

Addictions:

No

Family history:

No similar complaints in the family.

Menstrual history:

Attained menopause 15 years ago.

Vitals at presentation:

Temp: 99.1 F

PR : 110 bpm

BP : 140/80 mmHg

SpO2 : 99% @ RA

GRBS : 216 mg/dl.

Course in hospital:

A 64 year female was brought to casuality with above mentioned complaints, upon arrival to ER, on examination patient had bilateral lower lobe crepts and diffuse wheeze in bilateral lung fields. Her room air stats were 99%, she was managed by medicine resident on duty by nebulization with salbutamol and abg was taken at room air.

pH: 7.009

pCo2: 14.7

pO2: 60.6

HCO3-: 3.5

SaO2: 82.1

FiO2: 21%

s/o partially compensated metabolic acidosis.

300 meq of sodium bicarbonate correction was given as slowly via IV in the ER. Meanwhile necessary investigations were sent. 

ECG:



Chest x ray :



After shifting patient to ICU, a screening usg abdomen was done which showed raised echogenicity of bilateral kidneys. Inview of raised leucocyte counts and fever spikes, blood and urine cultures were taken and sent to lab. Patient was transferred to nephrology i/v/o raised urea and creatinine. Patient was in altered state at time of cross consultation by nephrologist. A Right femoral vein double lumen catherization was done and patient was taken up for hemodialysis. Before shifting patient to hemodialysis, he had an episode of GTCS, lasted for around 2 minutes, and stat dose of antiepileptic agent was given. patient was initiated on dialysis. Patient underwent intadialysis PRBC transfusion during 1st and 2nd HD session. Patient sensorium has improved after 2nd hemodialysis, but fever spikes still present and after 1 days she again detoriated and decline in sensorium was noted. In view of persistant fever spikes and decline in sensorium with near normalization of Uremia, thought of other focus for fever spikes. Patient was reevalauted and found that she was having a swelling of right knee associated with tenderness, with no background history of trauma, with no local rise in temperature. Arthocentesis was done under asceptic precautions and 40 ml of fluid was aspirated and aspirated fluid was turbid (pus) which was sent for Cytology and culture and senstivity.

Blood and urine cultures reports showed growth of E.coli. 

Urine for culture and sensitivity:



Blood for culture and sensitivity:



Arthocentesis:





2D echo:

RWMA : LAD territory hypokinesia; RCA and LCx territory hypokinesia; Paradoxical IVS

Moderate MR; Moderate AR

Moderate TR with PAH

EF 46%

moderate LV dysfunction 

Calcified AV; no As/MS

IVC 1.26 cms, collapsing. 

INVESTIGATIONS CHART:



On on day 7 of admission patient was started on Intravenous Vancomycin and Ciprofloxacin; stopped Piptaz.

Patient attendees have directly approached the arogyasree and opted for LAMA; as staying in hospital their are unabble to earn the livelyhood.

Provisional diagnosis:

1. Altered sensorium 2° to uremic encephalopathy.

2. GTCS 2° to Uremia.

3.Chronic Renal Failure

4. Hypertension • 6 months

5.Denovo Diabetes 

Management:

1. Ryles tube feeding.

2. INJ. PIPTAZ 2.25 gr/IV/TID 

3. INJ. LASIX 40 mg/IV/BD

4. TAB. SHELCAL 500 Mg/RT/OD

5. TAB. OROFER XT /PO/OD

6. INJ. HUMAN ACTRAPID INSULIN /SC/TID ACC. TO GRBS.

LEARNING POINTS:

1. As per the history given by the attendees, patient was experiencing breathlessness since a year. 

And their is no evidence regarding other symptoms like orthopnea, chest pain, palpitations, but baeedon radiological evidence of pulmonary edema, one can conclude she was having some sort of issue in her heart.

2. History of decreased urinary output and fever, would point towards decreased Renal function due to infection.

3. Pedal edema might be secondary to Heart failure and sepsis related hypoalbuminemia. 

4. Regular dialysis hasn't made any Improvement in her sensorium, even after decreased uremia. Point of focus went towards sepsis causing encephalopathy.

Thoughts:

The Unseen Challenges of Medical Practice: A Tale of Septic Arthritis, Arthrocentesis, and the Struggle for Patient Compliance

In the world of medicine, every day brings new challenges and opportunities to make a difference. As a postgraduate in general medicine, this case highlighted the complexities and frustrations that can accompany even the most diligent medical care. Here is the story of a patient with altered sensorium whose journey underscores the critical role of diagnostic acumen and the harsh realities of patient compliance.

Case Presentation

A middle-aged patient was admitted with altered sensorium. Initial evaluations indicated uremia, leading to the initiation of hemodialysis. Despite multiple sessions, the patient’s sensorium showed no improvement, prompting me delve deeper into possible underlying causes.

Diagnostic Puzzle

As the patient's condition did not improve with hemodialysis, I suspected an infectious etiology. During a thorough physical examination, subtle signs of joint involvement—mild swelling and tenderness in the knee were detected, raising the possibility of septic arthritis as a source for her altered sensorium

The Procedure: Arthrocentesis

Arthrocentesis was performed to investigate the suspected septic arthritis; which involves aspirating synovial fluid from the joint, was conducted with precision and aseptic technique. The fluid analysis revealed a high white blood cell count and the presence of bacteria, confirming an infective etiology. This diagnosis explained the persistent altered sensorium, likely due to systemic infection spreading from the infected joint.

A Glimmer of Hope: Treatment Initiation

With a possible diagnosis, the postgraduate promptly initiated targeted antibiotic therapy based on the sensitivity profile of the cultured organisms. 

Unexpected Turn: Leaving Against Medical Advice (LAMA)

Despite the careful diagnosis and initiation of appropriate treatment, the patient’s family decided to leave the hospital against medical advice (LAMA). This decision came despite extensive reassurances from the postgraduate about the patient’s condition and the provision of financial support through the Arogyasree program, which offered free treatment.

The patient’s family cited the impact on their daily livelihood as the reason for their decision. As daily wage earners, they were unable to sustain the constant hospital visits required to care for the patient, fearing that this would compromise their ability to earn a living.

The Aftermath

The premature discharge of the patient posed significant risks, leading to death of the Patient. The medical team were left feeling frustrated and helpless, knowing that their efforts to provide optimal care were undermined by factors beyond their control.

Reflections and Lessons

1. Comprehensive Education to Patient family:  

It is crucial to ensure that patients and their families fully understand the severity of the illness, the importance of continuous treatment, and the risks associated with non-compliance.

2. Addressing Socio-Economic Barriers: 

Socio-economic factors play a significant role in patient decisions. Providing financial support through programs like Arogyasree is essential, but understanding and addressing the broader impact on families daily lives is equally important.

3. Holistic Support Systems: 

Patient advocates can help bridge the gap between medical care and the socio-economic realities faced by patients and their families.

4. Building Emotional Resilience: 

For healthcare professionals, developing emotional resilience is crucial. Not all cases will end as hoped, and learning to navigate these outcomes is a part of the medical journey.