Name : Francisco, William

Age : 63 years old

Sex : Male

Chief Complaint : Generalized body weakness.

This is a case of 63 year old male, known HASCVD, T2DM and CKD,
admitted due to generalized body weakness and body malaise and drowsiness,
initial impression was Uremia probably secondary to CKD secondary to DM
Nephropaty, due to OPD Creatinine result of 620 mmol/L. Work up done to
patient.
Due to body weakness patient was referred to Neurologist service and also
referred back to Cardiology service, Endocrinology service, and Rheumatology
service.
Neurology service ordered for MRI of the brain to rule out CVA, and also for MRI
of the back to rule out spinal cause of the weakness. Brain MRI shows no acute
infarct, no hemorrhage or mass, cerebro atrophy noted. Cervical spince MRI
shows mild disc bulges of C3-C4, no edema noted, no bone fracture seen. LS
Spine shows disc bulges on L3-L4,L4-L5 and disc protusion on level L5-S1. Neuro
and Rheuma service then agreed to do EMG and NCV. Hence GBS and steroid
induced myopathy was diagnosed. ( Patient has been self medicating with
steroid for > 20 years).
Neurology service then started patient with IVIG, Rheumatology service then
work up patient for autoimmune disease, and maintain patient on low dose
steroid.
Cardio wise, renal, and endocrine wise, patient is clinically stable.
On the _____ hospital day, there was note decrease in Hemoglobin and platelet
count. Patient was then referred to Hematology service, with working
impression of Anemia, Thrombocytopenia, multifactorial. Blood transfusions
then was done.
At this time , patients motor function continues to improve.
On the ____ hospital day, patients had episode of Melena, hence patient was
referred back to Gastroenterology service ( patient was seen by GI service 1
month ago, EGD done noted ulcers). On repeat EGD, patient noted to have gastric
ulcer, erosive nodular duodenitis, esophagitis. PPI drip was then started.
Again at this time, there is improvement on the motoric strength of the patient.
On the ____ hospital stay, CXR was done noted to have pneumonia. Patient was
put on BIPAP but does not tolerate BIPAP, where DOB and desaturation was
seen, hence patient was put on mechanical ventilator.
Again blood works was done and noted patient to have Low ANC, hence Febrile
neutropenia complicated by pneumonia was diagnosed.
Upon medical Junta, patient was referred to Infectious Disease service, with
impression of HAP, t/c aspiration pneumonia, and febrile neutropenia. Patient
was then started with antibiotics.
During this time, patient noted to have increasing in creatinine, hence vascular
access was inserted for hydration,CVP and HD access, and patient was ordered to
transfere to ICU.
On Day _____ of admission, GI bleed continued, medication maximized, EGD and
colonoscopy was offered, but was not pursued due to patients condition.
Supportive BT was done to maintain hemoglobin at an accepted number.
On day ____ of admission, melena stopped, with improving of ANC, and improving
of motoric strength, but creatinine was seen to elevate.
On day _____ of admission, due to the persistently increasing creatinine, initiation
of renal replacement therapy was started.
Medical management continues to be maximize.