MEDICAL REPORT/DISCHARGE SUMMARY
U.M/ 53YRS/FEMALE
Diagnosis:
1.
Aki Secondary To Polypharmacy
2.
Degenerative disease of the lumbosacral
spine
Date of Admission: 8/7/2023
Date of discharge: 2/8/2023
Background
presentation and history:
The above named patient who was brought in from
Makurdi on account of reduced level of consciousness x 2days duration.
She is a 53 years old female, who started to develop
reduced level of consciousness. It initially started as complaints of ankle
pain which later radiated to the waist. she then took a medication which could
not be ascertained. She later developed reduced level of consciousness (lucid
intervals), however no lateralizing signs, no seizures, no history of chest
pain, no orthopnea, no dyspnea, no headaches, nausea and vomiting.
A known hypertensive and diabetic patient, duration
could not be ascertained. She is also on
tabs galvusmet 50/1000mg, tabs bisoprolol 10mg, tabs torsemide, tabs pregabalin
75mg, tabs gabapentin, tabs vasoprin, tabs clopidogrel, etc.
Neurology:
CNS: GCS= 14/15 (E-4, M-5, V-5), pupils 3mm reactive
bilaterally, normal tone, power and reflexes in all limbs. No cranial nerve
deficit noted.
BP= 115/78mmHg, PR= 78b/m, SPO2= 96%. (on INO2 4L)
Imaging
Brain CT Scan done showed no visible ischaemic
changes, No SOL
Assessment: ?cause of
lucid interval of unconsciousness r/o polypharmacy induced unconsciousness.
Management Plan:
1.
To do FBC, EUCR, LFT, FLP, clotting profile
2.
Chest X-ray, ECG
3.
For cardiology review
4.
IV ceftriaxone 1g 12hrly x 24hrs
5.
IVF N/S 1L 8hrly x 24hrs
6.
Subcut clexane 40iu stat
7.
Review of medications
8.
Discuss with neurosurgeon.
UPDATE 9/7/2023
A 53 years old female, she is a known diabetic and
hypertensive patient. She was admitted 1/7 ago on account of varying levels of
unconsciousness.
FBC= wbc- 11.33, hct- 35, plt- 373
EUCR= Na- 138.7, K- 3.55, Cr- 4.44, Ur- 133.3
LFT = AST- 433.1, ALP- 246.9, Alb-3.10
Abd/pelvic USS- essentially normal study
Serology= non reactive
PLAN:
1.
To be reviewed by the Nephrologist, cardiologist
and gastroenterology.
Cardiology Review
Patient seen, A 53yr old obese woman with confusion, who is
not oriented in person. A known hypertensive who was on multiple medications
BP- 117/53mmHg
PR- 76BPM
Based on above history and examination, not a current
cardiology case
Assessment : delirium sec to UTI
Plan:
1-
To have urine mcs and urinalysis
2-
To see in 2/52
UPDATE 10/07/2023
2 Days on admission on account of impairment of
consciousness and irrational thoughts.
Urgent brain CT scan ruled out any form of stroke. Further
investigations reveal the following
1.
Obese
2.
Impairment of urea and creatinine
3.
Proteinuria and hematuria.
Presently increasing irrational thoughts observed. Also
suspicious derangement on liver enzymes but no jaundice. History of
polypharmacy suggest drug induced renal toxicity.
PLAN:
1.
Daily EUCR check
2.
Review by nephrologist
3.
Cardiology review already noted
4.
Continue oxygen support and other management
UPDATE 11/7/23
Patient remains stable. Biochemical parameter shows a drop
in Creatine from 4.4mmol/L to 3.3mmol/L.
However, urea remains basically same about 134mg/dL. LFTs are almost
normalized now.
PLAN:
1.
To send blood this morning for EUCR
2.
Continue other medical treatment as prescribed.
Nephrology Review
Patient seen, EUCR – creatinine noticed to be on a down ward
trend, however urea is still elevated
Assessment: AKI ?Dehydration
Plan: to rehydrate approprately
UPDATE 12/7/23
FBC and LFT within normal range
EUCR: Na- 137.9, K- 3.09, Ur- 134.6, Cr- 1.48
ASS: hypokalemia and hyperurecimia
PLAN:
1.
Add tabs slow K 600mg tds x 5/7
2.
Continue other management
UPDATE 17/07/23
Clinical and biochemical parameter suggests reasonable
improvement. Creatinine is normalized and urea is on a downward trend though
slowly.
Current concerns are bilateral ankle pain which limits
movement. She is currently on xarelto, but mechanical prophylaxis is
constrained by pain and tenderness in both ankles.
PLAN:
1.
Continue ongoing management for AKI
2.
Do uric acid estimation for gouty arthritis.
ORTHOPAEDIC REVIEW
21/07/23
A 53 years old female, she is a known diabetic and hypertensive
patient. There is pain in the lower limbs, sharp/burning sensation distal to
the mid-leg which increases when she turns in bed, attempts to sit or roll.
Mere touching of skin increases pain.
Other prior history noted.
O/E: tenderness to mild touch
ASS: ? lumbar radiculopathy
PLAN:
1.
Do MRI spine and review
2.
KIV epidural injection.
OPERATION NOTE
26/7/2023
Lumbar Epidural injection administered into the L4/5 space,
cocktail of 80mg triamcinolone and 2mls of 0.25% macaine.
Procedure was well tolerated.
Pre-injection
workup:
VAS= 9/10
ODI=78%
PLAN:
1.
Return to the ward and monitor
2.
Update report
3.
Repeat VAS and ODI in 2 weeks
4.
Tabs pregabalin 150mg bd x 2/52
UPDATE 27/07/2023
Some symptomatic improvements have been recorded on
medications and minimally invasive treatments such as Tabs Lyrica 150mg bd and
lumbar epidural injection.
It is therefore confirmed that she has lateral recess
syndrome involving L3/4, L4/5, L5/S1 foramen entrapment of exiting nerves.
For long term pain relief, a primary non-instrumented micro-foraminotomy
is recommended.
Meanwhile continue current medication until informed consent
procedures are completed.
UPDATE 30/07/2023
Patient’s complaint of pain on her right ankle has reduced,
while that of left ankle has markedly resolved. She has been counseled on
instrumented micro foraminectomy for long term pain relief. Currently, she is
on tabs pregabalin, and other analgesics. She had physiotherapy yesterday and
was able to stand with support and was also able to sit out of bed.
PLAN:
1.
Continue physiotherapy
2.
Continue analgesics
3.
Discontinue urethral catheter.
UPDATE 01/08/2023
A 53 years old female, she is a known diabetic and
hypertensive patient. Complaint of bilateral ankle pain is markedly subsiding
following epidural injection administered 6/7 ago.
There are no fresh complaints as of today.
PLAN:
1.
Repeat uric acid check
2.
For possible discharge tomorrow
3.
Continue physiotherapy as outpatient
Discharge medications
and instructions:
·
Tab Cocodamol ii bd
·
Tabs HCT 50mg daily
·
Tabs Amlodipine 10mg faily
·
Tabs Valsatan 160mg AM and 80mg nocte
·
Tabs Lyrica 150mg bd
·
Tabs Xarelto 10mg alternate days
·
To continue on physiotherapy
·
For spine surgery when ready
Review in 2/52 16th August 2023 .
However you can come earlier if there are any concerns.
Kindly revert to us for further clarifications where
necessary.
Yours Sincerely
Dr. Ozoemena O.F
For Team Wellington Clinics Abuja.