Sripadi Shirisha Rollno151

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                                                                                   December 29 ,2021                                                                                                                                                                                                                                 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 knee

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 

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

- 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 

26/12/2021

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 awaite.

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.