Karima Abd Elhamid Hamed a 72 year old female patient, divorced, has two off

springs, the youngest is 38 yrs old.

She lives alone, in Ain Shams in a flat in the second floor, with high seated toilet
and a separate kitchen.

The patient is illiterate, a house wife, financially supported by her daughter's

income which is not satisfactory.

She has no special habits of medical importance

Primary Health Problem from her daughter's Prospective:

Disturbed conscious level of acute onset and progressive course of three hours
duration.

Past history:

1. Past medical history:

- Diabetes mellitus from 18 years ago, she started with oral hypoglycemic
drugs but wasn't controlled so shifted to insulin mixtard 40 units at the
morning only,complient but still uncontrolled with no regular follow up. It
was complicated with peripheral neuropathy, diabetic foot and left lower
limb below knee amputation 5 years ago and she became bed ridden
eversince. also complicated with recurrent hypoglycemic coma which is
rapidly reversed with iv glucose and didn’t need hospital admission.
- Hypertension 15 yrs ago and didn't receive any medical treatment and no
regular follow up.
- Chronic constipation 10 yrs ago (1 motion every 3 days and her regular
bowel habit was one motion / day) and she is on regular use of laxatives
- Ischemic heart disease 5 yrs ago when she developed chest pain and was
diagnosed with MI, 6 stents were inserted and she was admitted to CCU for
4 days after and later was discharged on Plavix 75 and aspocid 75
- CHF 5 yrs ago with frequent hospital admissions due to recurrent
decompensation where she received diuretics and antifailure drugs and
discharged on Examide 10 and Concor 2.5
 2- As regard past surgical history:

Name of operation: Amputation of left lower limb below the knee

Date 5 yrs ago
Hospital Eldemerdash university hospital
Anesthesia general
Blood transfusion Yes

Name of operation: Rt. Eye cataract

Date 4 years ago
Hospital Eldemerdash university hospital
Anesthesia local

3- No history of allergy to any drug or food

4- no history of previous accidents or injuries:
- As regard sensory impairment:
- There's visual impairment not affecting her quality of life and no eye glasses
- There's also hearing impairment not affecting her quality of life and no
hearing aid
5- As regard activity pattern: patient sleeps 6 hours at night (interrupted)
with one day nap which is unsatisfactory for her.
She spends her time watching TV
6- As regard health promotion: Chemoprophylaxis with aspocid and Plavix
No cancer screening, No immunizations, No regular medical follow up, No
regular exercise and No dental care.

Description of major health problem:

The condition started three hours before coming to the ER when she developed
disturbed conscious level of acute onset, progressing from inattention and
disorientation to she became stuperous when she came to the ER, it was associated
with palpitation and severe sweating, no history of head trauma, no symptoms of
meningitis, no symptoms of increased intracranial tension ( projectile vomiting,
severe headache, blurring of vision) no symptoms of lateralization.
this was associated with a one week history of productive cough with yellowish
sputum of moderate amount not related to posture, progression of her dyspnea
from dyspnea with exertion to dyspnea at rest, orthopnea and bilateral LL edema of
gradual onset and progressive course, also associated with symptoms of low
cardiac output in the form of headach, dizziness and cold extremities, following
her admission to the nasr city Health insurance hospital one week ago with
decompensated HF, no PND, no cyanosis, no chest pain, no hemoptysis, no
jaundice, no dyspepsia, no ascitis and no right hypochondriac pain.

By reviewing other systems no symptoms suggesting other system affection.

- EXAMINATION:
- MMSE: 26 / 30 (lost 1 in recall, 1 in drawing, 1 in reading and 1 in writing)
and it is average for her age
- GDS: 5 /15 ? ( positive for depression)
- ADL: dependent in all except feeding(independent) and assisted in dressing
- IADL: dependent in transportation, preparing meals, shopping, handling
money and house work, assisted in using telephone and medication.

GENERAL EXAMINATION:

Patient was stuperous in the ER and started to gain consciousness after taking IV
glucose.
No special facies and she was orthopnic.
Vital data:
- Blood pressure 110/70
- Pulse 80 b/m, regular, of average volume, equal on both sides, with no .
special character.
- Temperature: 37.5 oc
- Respiratory rate 18-22 b/m.
Complexion: there is no pallor, no jaundice nor cyanosis.
Head and neck: congested neck veins, no thyroid enlargement, No scars of
previous operations, No palpable lymph nodes enlargement.
Upper limb: No clubbing, No tremors, No palmer erythema and No axillary
lymph nodes enlargement.
Lower limbs: Amputation of left lower limb below the knee, bilateral LL pitting
edema up to anterior abdominal wall, there is no hotness, redness, tenderness, felt
peripheral pulsations and lax Rt calf muscles, multiple ulcers on the right toes.
2nd degree gluteal pressure ulcer
CARDIAC EXAMINATION:

Inspection: no pericordial bulge, no scars of previous operations, no visible

pulsations.
Palpation: Apex not felt, epigastric pulsations ( mostly aortic
pulsations)
Percussion: dull bare area of the heart With no dullness outside the apex, at the
base or right border of the heart.

Auscultation: regular s1 &s2 ,No audible murmurs

CHEST EXAMINATION:

Inspection: normal Shaped chest, symmetrical, no scars or dilated veins

Palpation: equal chest expansion, equal TVF, trachea in mid line , no tenderness or
palpable ronchi
Percussion: resonant bilaterally MCL, MAL, kronigs ismuth, dull bare area of the
heart
Upper border of the liver located at 6th intercostal space
Auscultation: equal air entry, harsh vesicular breathing
Additional sounds: on admission there was coarse crepitations and fine basal
crepitations and later on only there was fine basal crepitations
ABDOMINAL EXAMINATION:

Inspection : normal abdominal shape, thoracoabdominal movement, right SCA,

umbilicus is at midline and inverted, no divercation of recti , normal
hair distribution, no swelling per hernia orifices, no scars , no dilated
veins
Palpation: superficial: no masses, no tenderness, no rebound tenderness, no
rigidity.
Deep : no palpable organomegaly
Percussion : no ascitis by shifting dullness , no suprapubic dullness.
Auscultation: audible intestinal sounds.

NEUROLOGICAL EXAMINATION:

Patient was stuperous on admission then she gained her consciousness after
receiving IV glucose10%
Speech: intact
Gait: cant be assesed
Cranial nerves: intact
Motor : state: no atrophy nor hypertrophy
Tone: no hypotonia nor hypertonia
Power: no weakness
Reflexes : elicited superficial reflex
Deep: UL: elicited brachioradialis , biceps and triceps reflexes
LL: lost Rt ankle reflex, elicited knee reflex
No pathological reflexes
Sensations: Rt side stock hypothesia
Intact coordination

MUSCULOSKELETAL EXAMINATION:
No deformities, no swellings, left side below knee amputation
Bilateral knee crepitus

Hospital course:
Patient came to the ER with disturbed conscious level (stuperous most probably
hypoglycemic coma as RBS was 25 and she regained her consciousness rapidly
after infusion of glucse 10% ),also she was hypoxic and distressed Sao2 80% on
RA so She received O2 by nasal cannula (4L & SaO2 become 94%).
CT brain &CT chest were done and Covid was suspected also with raised D dimer,
the patient was isolated and 2 PCR were done and were negative so She transferred
to ICU & antifailure drugs introduced gradually starting with capoten and
aldactone and procolan added on HR 100 bpm but she became bradycardic HR 50
bpm so procolan was stopped. Urine & blood cultures were obtained at the peak of
the fever and broad spectrum Abs were started till the cultures results appear, Also
diflucan was started as urinary moniliasis was detected, and when her O2 demand
improved and became on 2L NC, she transferred to IMCU on 28/11 to monitor
HR, Thyroid profile was done to exclude hypothyroidism as a cause of bradycardia
& it was normal, also capoten and aldactone were stopped due to hyperkalemia,
and when K level returned to normal they were introduced again and when
bradycardia resolved with improvement of her chest condition and symptoms of
decompensated HF, she was transferred to the ward to complete her workup.
At the ward she received physiotherapy and continued her Abs course and her O2
requiements improved as she became on RA.

There were ulcers on the Rt toes and surgery consultation was done, and they
recommended controlling diabetes (RBS<200), daily dressing with saline and
iruxol, X-Ray on the Rt foot and vascular consultation was done and recommended
CT-Angiography on lower limb, abdominal aorta, both lower limb arteries also Rt
lower limb duplex.

PAUS was also done and when her general condition improved and stabilized, she
discharged to home.

Investigation

 HRCT of Chest (23-11) showed bilateral diffuse reticulation mainly

peripheral with GGO, cardiomegaly, CGB.
 CT brain (23-11) showed age related changes
 Urine analysis (23-11) pus cells 20-25 and monilia +2 and the urine catheter
changed
Then repeated on 27-11 and still monilia +2 so we started diflocan
 COVID-19 pcr (23/11 & 25/11) negative
 Urine culture (24-11) pseudomonas and klebsiella MDR
 Sputum culture (24-11) pseudomonas sensitive to maxipime, tazocin and
fortum
 Echo (27-11) showed EF30-35%, dilated LV and RV, impaired LV and RV
systolic function, no pericardial effusion.
 PAUS (1-12) showed hepatomegaly(16 cm) with gall bladder stone
measuring 5mm, no ascites
  Duplex on the right LL (2-12) showed diffuse atherosclerotic changes,
multiple calcified plaques and monophasic waves
 X-Ray on the right LL(4-12) which was normal

 Labs

on On
admission discharge
HGB with mcv 8.5 8.9
85
tlc 9 6
lymph 1.9 1.1
plt 217 300
crp 308 5
inr 1 1.2
d-dimer 2.4
ferritin 22 38
Bun 16 20
creat 0.8 0.9
Na 132 138
K 4.1 3.9
then5.4
Ca 2 9 9.4
Po4 3.7 2.6
mg 1.7 2.2
Ast 16 13
Alt 11 9
Albumin 3.2
Ck total (25- 64 17
11)
Ckmb(25-11) 13 16
troponin 0.02 0.006
 on On
admission discharge
Triglycerides 122
1/12
Cholesterol 137
Hdl 42
LDL 70.6
TSH 29/11 3.7

Problem list

Resolved hypoglycemic coma, decompensated HF, hospital acquired

pneumonia, resolved bradycardia and resolved hyperkalemia ,UTI, HTN,
DM complicated with diabetic foot and left LL below knee amputation,
IHD with 6 stents insertion,chronic constipation, normocytic
normochromic anemia, 2nd degree gluteal pressure ulcer. Ischemic
ulcerations of the right toes, single gall bladder stone, operated right
eye cataract, visual and hearing impairment, depression, living alone
and financial issues

Drugs administered:

Tavanic 750mg once daily iv (23-11 till 30-11)

Linezolid 600mg bid oral (23-11 till 30-11)

Diflocan 200 mg once daily iv(27-11 till 6-12)

Maxipime 2gm tds iv according to the sputum culture (27-11 till 3-12)
Capoten 25 mg 1/4 tab tds oral

Aldactone 25mg once oral

Lasix 40mg bid iv then shifted to oral on discharge

Concor 1.25 then 2.5 mg

Nitromac 2.5 mg bid oral

Aspocid 75mg once

Plavix 75mg once

Ator 40 mg once

Clexan 40 units once subcutaneous

Controloc 40 mg oral

Picolax 15 drops bid

Insulin mixtard 15 ∕ 15 subcutaneous

Calmag tab bid

Oplex tds orally

Mebo tds

Iruxol cream bid

Praxilene 200 mg tds orally as recommended by vascular department