A 58 year old male
This is a case of a 58 year old male farmer(8acre land) & Toddy collector
Pt was apparently alright 11 months ago,one day after a heavy work in his farm ,He had body pains and at night he developed involuntary movement of right upper limb & lower limb with loss of consciousness for 1hr(No involuntary micturation/Defecation) and was taken to Balaji hosp in miryalaguda,pt had irrelevant talk for 2day’s,as his condition was not improving he was shifted to sunshine hyderabad.After which,his condition improved and in 3days he was discharged with some antiepileptic medication
6month back he went for follow up in sunshine for focal seizures/Focal dystonia he was given tetrabenazine 25mg(1/2tab BD)
Haloperidol 0.5mg(1/2tab TID)
Clonazepam(0.25mg mng,0.5mg n8)
Sodium valproate(300mg x Bd)
After 1month went to neurologist in miryalaguda,he was given carbamazepine 400mgxBD& Tetrabenazine25mg xBD(now he is still continuing these medication)
Since 11months pt stopped working,he was getting his daily livelihood from Govt schemes(ra itu bandu,Paniki aahara pathakam)
15day’s back pt went for fishing in near by pond got half kg pamphlet fish.He used to get into pond till water covering his thigh’s
Last Thursday(17/6/2021) he went to same pond for fishing at 1:00pm in afternoon,his fishing continued till 4:00pm.Next day(friday) he developed severe pain in the left knee with lf leg swelling,went to local medical hall,got 4tablets of painkiller’s,took 2 tablet’s,pain subsided for 6hr’s & again pain recurred in evening which didn’t relieved after taking medication
Saturday(19/6/2021) his wife noticed hyperpigmented patch over left knee & above ankle.
Sunday(20/6/2021) went to hospital in miryalaguda,routine test wer done,Report’s showed Hb-8.6,TLC-1200,Plt count-24k,ESR-70mm,CRP-101 mg/dl,Sr creat-0.6.He was referred to our hospital.
From Monday (21/6/2021) pt developed severe pain in the lesion area’s & increasing in size,pt was not able to walk bcz of pain.
Today(22/6/2021) they came to our hosp for further treatment
PERSONAL HISTORY:
• Married
• Normal appetite
• Mixed diet
• Bowels regular
• Normal micturition
• No known allergies
• Habits/Addictions: toddy
FAMILY HISTORY:
Not significant
PHYSICAL EXAMINATION:
GENERAL:
• Pallor present
,Icterus, Cyanosis,Koilonychyia, Clubbing, Lymphadenopathy absent
Edema of feet present,left foot more than righ
VITALS:
• BP: 110/60 mmHg in supine
On standing : 130/60mm hg
• PR: 115bpm
• RR:18cpm
• local rise of temp present,peripheral pulses present
• SpO2: 98% @ RA
Fever chart :
WBC count chart :
SYSTEMIC:
CARDIOVASCULAR SYSTEM:
• S1,S2 heard
• No murmurs
• No thrills
RESPIRATORY SYSTEM:
• Position of trachea: Central
• Breath sounds: Vescicular
• Adventitious sounds: None
•inspiratory wheeze present
ABDOMEN:
• Shape: Scaphoid/Obese
• Bowel sounds: Heard
CENTRAL NERVOUS SYSTEM:
• Conscious
• Normal speech
INVESTIGATIONS :
BLOOD UREA:
Chest Xray :
Treatment :
Day 1 :
IVF - NS,DNS,RL @ 100ml/hr
Doxycycline 100mg PO/BD
Tab.pantop 40mg PO/OD
Inj.zofer 4mg iv/tid
Tab.dolo 650mg PO/QID
Inj.neomol 100ml/iv/sos if temperature more than or equal to 101 degrees
Tab.Carbamazepine 200mg PO/BD
Tab.phenytoin 100mg PO/TID
Inj metrogyl 100ml/iv/tid
PR/BP/TEMP charting 2nd hourly
Grbs 6th hourly
Tab fluconazole PO/OD
Inj.Cetazidime 1gm/iv/tidIVF - NS,DNS,RL @ 100ml/hr
Day 2 :
Doxycycline 100mg PO/BD
Tab acelofenac 100mg PO/BD
Tab.pantop 40mg iv/OD
Continuous tepid sponging
Inj.zofer 4mg iv/t
Nebulization with duolin PN/BD, budecort PN/TID
Tab.dolo 650mg PO/QID
Chlorhexidine mouth wash
Inj.neomol 100ml/iv/sos if temperature more than or equal to 101 degre
Inj vancomycin 1gm in 200ml NS or slow IV
Tab.Carbamazepine 200mg PO/OD
Tab.phenytoin 100mg PO/TID
Inj metrogyl 100ml/iv/tid
PR/BP/TEMP charting 2nd hour
Grbs 6th hourly
Tab fluconazole PO/OD
Inj.Cetazidime 2gm/iv/tid
Day 3 :
Decreased temperature
Doxycycline 100mg PO/BD
Tab acelofenac 100mg PO/BD
Tab.pantop 40mg iv/OD
Inj.zofer 4mg iv/t
Nebulization with duolin PN/BD, budecort PN/TID
Tab.dolo 650mg PO/QID
Chlorhexidine mouth wash
Inj.neomol 100ml/iv/sos if temperature more than or equal to 101 degre
Inj vancomycin 1gm in 200ml NS or slow IV
Tab.Carbamazepine 200mg PO/OD
Tab.phenytoin 100mg PO/TID
Inj metrogyl 100ml/iv/tid
PR/BP/TEMP charting 2nd hour
Grbs 6th hourly
Inj .optineuron 1amp in 100ml NS/iv/OD
Tab fluconazole PO/OD
Inj HAI
Day 4 :
Doxycycline 100mg PO/BD
Tab acelofenac 100mg PO/BD
Tab.pantop 40mg iv/OD
Inj.zofer 4mg iv/t
Nebulization with duolin PN/BD, budecort PN/TID
Tab.dolo 650mg PO/QID
Chlorhexidine mouth wash
Inj.neomol 100ml/iv/sos if temperature more than or equal to 101 degre
Inj vancomycin 1gm in 200ml NS or slow IV
Tab.Carbamazepine 200mg PO/OD
Tab.phenytoin 100mg PO/TID
Inj metrogyl 100ml/iv/tid
PR/BP/TEMP charting 2nd hour
Grbs 6th hourly
Inj .optineuron 1amp in 100ml NS/iv/OD
Tab fluconazole PO/OD
Inj HAI
Inj filgastrim 300mcg/SC/BD 2 days
Day 5 :
Doxycycline 100mg PO/BD
Tab acelofenac 100mg PO/BD
Tab.pantop 40mg iv/OD
Inj.zofer 4mg iv/t
Nebulization with duolin PN/BD, budecort PN/TID
Tab.dolo 650mg PO/QID
Chlorhexidine mouth wash
Inj.neomol 100ml/iv/sos if temperature more than or equal to 101 degre
Inj vancomycin 1gm in 200ml NS or slow IV
Tab.Carbamazepine 200mg PO/OD
Tab.phenytoin 100mg PO/TID
Inj metrogyl 100ml/iv/tid
PR/BP/TEMP charting 2nd hour
Grbs 6th hourly
Inj .optineuron 1amp in 100ml NS/iv/OD
Tab fluconazole PO/OD
Inj HAI
Inj filgastrim 300mcg/SC/BD 2 days
Provisional diagnosis
Pancytopenia under evaluation
Left lower limb cellulitis with known case of bronchial asthma since childhood and epilepsy since one and half year
Death summary:
A 55 YR OLD MALE CAME TO OUR HOSPITAL WITH COMPLAINTS OF BILATERAL LOWER LIMBS PAIN AND BURNING SENSATION OF LOWER LIMBS. ON PRESENTATION PATIENT WAS CONSIOUS , COHERENT , COPERATIVE , VITALS ARE STABLE WITH TEMPERATURE OF 100 F WITH CBP SHOWING PANCYTOPENIA. PATIENT WAS ON TAB. CARBAMAZEPINE 400 MG PO/BD SINCE 11 MONTHS AND KNOWN CASE OF BRONCHIAL ASTHMA. SO OUR PROVISIONAL DIAGNOSIS IS PANCYTOPENIA SECONDARY TO ? CARBAMAZEPINE INDUCED ? BONE MARROW SUPRESSION , FEVER WITH RASH SECONDARY TO ? ECTHYMA GANGRENOSUM AND FEBRILE NEUTROPENIA. PATIENT WAS STARTED ON FEBRILE NEUTROPENIA PROPHYLAXIS WITH INJ. CEFTAZIDIME , TAB. FLUCANOZOLE , INJ. METROGYL. HE WAS HAVING CONTINUOUS FEVER SPIKES FOR 3 DAYS FROM 101 TO 104 F AND WE ADDED INJ. VANCOMYCIN. WE TAPPERED THE DOSE OF CARBAMAZEPINE AND STOPPED ON DAY 3 OF ADMISSION AND STARTED ON TAB PHENYTOIN 100 MG PO/TID. PLATELET TRANSFUSION WAS DONE ON NEXT DAY OF ADMISSION IN VIEW OF LOW PLATELET COUNT. HBA1C - 6.9 AND GRBS MONITORING WAS DONE. INJ INSULIN GIVEN SUBCUTANEOUS ACCORDING TO SLIDING SCALE. IN VIEW OF PROGRESSIVE PANCYTOPENIA HE WAS GIVEN FILGASTRIM INJECTION SUBCUTANEOUSLY. TO KNOW THE PRIMARY CAUSE , BONE MARROW ASPIRATION AND BIOPSY WAS DONE [ REPORTS AWAITED ].
DERMA OPINION WAS TAKEN FOR HYPERPIGMENTED SKIN LESIONS. SKIN BIOPSY TAKEN [ REPORTS AWAITED ]. THEIR DIAGNOSIS IS FIXED DRUG ERUPTION SECONDARY TO ? CARBAMAZEPINE. BLOOD CULTURES AND FLUID FROM SKIN LESIONS SHOWED NO GROWTH.
PATIENT ATTENDEES HAS BEEN COUNSELLED ABOUT WHOLE BLOOD TRANSFUSION , SO WE COULD NOT HAVE AVVAILABILITY OF DONORS , ONE PRBC TRANSFUSION WAS DONE. PATIENT BECAME TACHYPNEIC , DROWSY ON DAY 6. CHEST X RAY SHOWED BILATERAL PULMONARY INFILTRATES - HOSPITAL ACQUIRED PNEUMONIA [ BACKGROUND OF SEVERE NEUTROPENIA ]. HIS SPO2 WAS 75 TO 80 % ON ROOM AIR AND O2 INHALATION GIVEN TO MAINTAIN THE SATURATION >92%. ABG WAS DONE SHOWING RESPIRATORY ALKALOSIS. ANTIBIOTIC ESCALATED TO MEROPENAM AND CONTINUED REST.
HE WAS HYPOTENSIVE SINCE 12 AM [ 28-06-2021 ] AND WAS STARTED ON INOTROPIC SUPPORT. INSPITE OF INCREASING INOTROPES PATIENT WASN NOT MAINTAINING BLOOD PRESSURE.
AT 5.10 AM , PATIENT HAD SUDDEN CARDIAC ARREST , BP/PR NOT RECORDABLE. CPR INITIATED AND INTUBATED WITH ET-7 M.
INSPITE OF ALL RESUSCITATIVE EFFORTS PATIENT COULD NOT BE REVIVED AND DECLARED DEATH ON 28/06/2021 AT 5.54 AM.
IMMEDIATE CAUSE OF DEATH - SEPSIS WITH REFRACTORY HYPOTENSION , TYPE 1 RESPIRATORY FAILURE
ANTECEDENT CAUSE OF DEATH - FEBRILE NEUTROPENIA WITH PANCYTOPENIA SECONDARY TO CARBAMAZEPINE / BONE MARROW SUPRESSION. FEVER WITH RASH ? ECTHYMA GANGRENOSUM ? FIXED DRUG ERUPTION [ SECONDARY TO CARBAMAZEPINE ] WITH HOSPITAL ACQUIRED PNEUMONIA [ BACKGROUND OF NEUTROPENIA ] WITH DENOVO DM-2 WITH KNOWN CASE OF BRONCHIAL ASTHMA AND EPILEPSY.
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