55 year old male came with the
C/o ulcers over both right and left buttocks since 2 months
C/o inability to pass urine since 1 day
HOPI :
Patient was apparently asymptomatic 9 years ago after which he fell from a palm tree and injured his back . Then he lost all the sensations from umbilicus to both lower limbs for which he was taken to a hospital in Hyderabad for treatment (unknown) and was discharged since they were told it wasn't possible to operate him or put any implants in lower limbs
Then he underwent ayurvedic treatment for few days and still there was no relief
Since then he was bedridden
2 months ago he developed bedsores first on left then on right .
H/o pus in urine present since 1 month ( but only sometimes )
H/o fever present since 1 month associated with chills , continuous type , partially relieved with medication
On 23/12/2021
He came to Kims narketpally due to inability to pass urine since 1 day .
General examination :
Patient is conscious coherent and cooperative
Pallor - present
Edema - B/L pedal edema pitting type present upto ankle
No cyanosis , clubbing , lymphadenopathy .
Vitals :
Temp -97.3 degree f
Pr - 103 bpm
Bp -100/80 mmhg
RR - 16 cpm
Spo2 - 99% @ RA
GRBS - 80 mg/dl
Systemic examination
Cvs-S1,S2 +
Rs-bae+
Cns .
Tone
UL. Normal. Normal
LL. Decreased. Decreased
Power of both lower limbs - 2/5
Sensory - loss of sensations from umbilicus to both lower limbs
Reflexes -
B T. Supinator
++. ++ ++ Right
++. ++. ++. Left
Lower limbs :
Ankle -
Knee -
Plantar -mute
Chest X-ray
Ecg
USG
Diagnosis-paraplegia secondary to traumatic spinal injury with pyelonephritis with grade 4 bed sore
Treatment
1. IVF fluids 2 NS at 80ml/hr
2. Inj Piptaz 4.5 g IV stat
3. Inj. Pan 40 mg IV stat
4. Inj pcm 1g IV sos
5. Monitor vitals and
Inform sos
6. Debridement and ASD done for bed sores
7. Position change 2nd hourly
25/12/2021
Icu bed no 5
S- decreased urine output, fever spikes since yesterday
O- Pt conscious, coherent
Pallor+
B/l pedal edema pitting type up to ankle +
Temp - 99f
BP- 100/70mmhg
PR- 89bpm
RR- 16cpm
Spo2- 98% at ra
Grbs- 92mg/dl
I/0- 1900/600ml
Rs - bae+
Cvs- s1s2+
P/a - soft , bs+
Cns - HMF intact
Pupils b/l reacting to light
Tone-
Rt. Lt
Ul. N N
LL. Dec. Dec
Power
Rt. Lt
UL. 5/5. 5/5
LL. 1/5 1/5
Reflexes
Rt. Lt
Biceps 2+. 2+
Triceps 2+. 2+
Supinator 2+. 2+
Knee- - -
Ankle. - -
Plantar Mute. Mute
Fine touch, crude touch, pain, temperature sensation lost from the level of umbilicus
A- Acute kidney injury sec to urosepsis
(? Lt side pyleonephritis)
Paraplegia sec to traumatic spine injury
Grade 4 bed sore
Anemia( microcytic hypochromic under evaluation)
Cue - alb 3+
Plenty of pus cells
Urea-114
CT-4.8
P- urine c/s were sent, report awaited
Ivf NS RL @75ml/hr
Inj piptaz 2.25gm iv tid
Inj pantop 40mg iv od
Tab pcm 650mg po sos
Frequent change of posture
Physiotherapy of b/l lower limbs
I/0 charting
Bp /PR / spo2 charting 4th hrly
Icu bed no 5
S- no fever spikes since yesterday
O- Pt conscious, coherent
Pallor+
B/l pedal edema pitting type up to ankle +
Temp - 99f
BP- 90/70mmhg
PR- 89bpm
RR- 16cpm
Spo2- 98% at ra
Grbs- 92mg/dl
I/0- 1900/600ml
Rs - bae+
Cvs- s1s2+
P/a - soft , bs+
Cns - HMF intact
Pupils b/l reacting to light
Tone-
Rt. Lt
Ul. N N
LL. Dec. Dec
Power
Rt. Lt
UL. 5/5. 5/5
LL. 1/5 1/5
Reflexes
Rt. Lt
Biceps 2+. 2+
Triceps 2+. 2+
Supinator 2+. 2+
Knee- - -
Ankle. - -
Plantar Mute. Mute
Fine touch, crude touch, pain, temperature sensation lost from the level of umbilicus
A- Acute kidney injury sec to urosepsis
(? Lt side pyleonephritis)
Paraplegia sec to traumatic spine injury
Grade 4 bed sore
Anemia( microcytic hypochromic under evaluation)
Cue - alb 3+
Plenty of pus cells
Urea-114
CT-4.8
P- urine c/s were sent, report awaited
Ivf NS RL @75ml/hr
Inj piptaz 2.25gm iv tid
Inj pantop 40mg iv od
Tab pcm 650mg po sos
Frequent change of posture
Physiotherapy of b/l lower limbs
I/0 charting
Bp /PR / spo2 charting 4th hrly
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