Endocrinology Unit Case Presentation.pptx.pdf

1. CASE PRESENTATION
ENDOCRINOLOGY UNIT
DR ASECHEMIE

2. ADMISSION LIST 30/11/2023
S/N NAME DIAGNOSIS OUTCOME
1 O.L Hemorrhagic CVA On admission
2 A.E Ischaemic CVA On admission
3 A.P Suicidal attempt 2 to moderate to severe depressive disorder Discharged
4 O.B SIRS 2 to decompensated psychosis Discharged
5 A.J Hemorrhagic CVA Deceased
6 A.V Obstructive jaundice 2 to ? Ca head of pancreas On admission
7 A.O Toxic Hepatitis with background CKD On admission
8 E.I Suspected intra abdominal malignancy Discharged
9 A.K VOC pptd by sepsis in a known HbSS On admission

4. BIODATA
Name : A.0
Age : 24 yrs
Sex : Male
Address: Ejigbo Lagos
Religion: Christian
Occupation: Student
Marital status: Single
Tribe: Yoruba
Informant : Brother & parents

5. PRESENTING COMPLAINT
Generalized body pain x 4/7
Fever x 2/7
Breathlessness x 2/7
LOC x 1/7

6. HISTORY OF PRESENTING COMPLAINT
Patient is a known HbSS diagnosed at childhood with poor clinic attendance though informant claimed
good drug compliance.
He was in his usual state of health until 4/7 ago prior to presentation when he developed generalized
body pain, insidious in onset, more in the back and lower limbs following vigorous exercise(cycling).
Severity of pain could not be ascertained.
There was hx of associated generalized headache. Severity and quality of headache could not be
ascertained.
Fever was said to have started 2 days after, described as high grade, intermittent without chills and
rigors.
Breathlessness was of sudden onset, both on exertion and at rest. Nil aggravating or relieving factors.
Nil hx of cough, chest pain, palpitations, orthopnea, PND or leg swelling.

7. He subsequently developed LOC a day prior to presentation. Nil hx of vomiting.
Nil hx of blurry vision, dizziness, syncope or seizures. Nil hx of photophobia or phonophobia
Nil previous hx of stroke or TIA.
Nil hx of jaundice, dysphagia, anorexia, nausea, hiccups, change in bowel habits or weight loss.
Nil hx of reduction in urine output, dysuria, passage of frothy urine, hematuria or facial puffiness.
On account of symptoms and LOC, he presented to a general hospital and subsequently referred
to LASUTH for expert care.

8. PAST MEDICAL HX
Known HbSS diagnosed at 2 yrs of age. Attends Isolo General Hospital for his clinic visits
Steady state PCV is 28%. Last crisis was 18 months ago.
Not hypertensive or diabetic .
Not asthmatic or epileptic
Nil hx of blood transfusions or previous surgeries
RVD & Hepatitis B status unknown
Covid 19 vaccine status unknown

9. FAMILY & SOCIAL HX
Nil family hx of similar symptoms
Last child born into a monogamous setting with 2 siblings with AS genotypes
Parents unsure of their genotypes
Doesn’t take herbal concoctions.
No hx of alcohol consumption, smoking or use of illicit drugs.

10. DRUG HX
No known drug allergies
Routine medications: Paludrine, Vit Bco, Folic acid

11. SUMMARY
A 24 yr old student known HbSS diagnosed in childhood with 4/7 hx of generalized body pain
worse in the back and lower limbs, 2/7 hx of high grade, intermittent fever, 2/7 hx of
breathlessness on exertion and at rest and 1/7 hx of LOC.
There was positive hx of generalized headache. Nil hx of seizures, vomiting, blurry vision.
Nil hx of previous stroke or TIA.
Nil hx suggestive of renal or hepatic decompensation.
No hx of alcohol consumption, smoking, illicit drug use, nil hx of blood transfusions, not
diabetic or hypertensive and no family hx of similar symptoms.
Last crisis was 18 months ago. Steady state PCV 28%

12. ADMITTING VITALS
PR - 114bpm
BP - 132/90mmHg
RR - 24cpm
SPO2 - 96% on INO2
RBS - 127mg/dl
T - 37.1C

13. DIFFERENTIAL DIAGNOSIS
VOC in a known HbSS r/o complicated malaria
Sepsis ? focus kiv Chest
LOC ? cause r/o CVA

14. PHYSICAL EXAMINATION
GENERAL EXAM
A young male, unconscious, in respiratory distress, febrile (T=38C), pale, icteric, acaynosed, not
dehydrated, nil pedal edema.

15. CNS
GCS : E 2 V 1 M 4 = 7/15
Pupils 3mm bilaterally reactive to light
Nil meningeal irritation
No focal neurological deficit
Tone : Global hypotonia
Power & reflexes could not be objectively assessed

16. CVS
PR 114bpm rapid,full vol,regular
BP 132/90mmHg
HS S1S2
AB 5th LICS LMCL

17. CHEST
RR 44cpm
SPO2 90–92% RA
94--96% INO2
BS: transmitted sounds globally

18. ABDOMEN
Scaphoid, soft, mwr
Nil area of tenderness
Nil liver, spleen or kidney enlargement

19. SUMMARY
A 24 yr old student known HbSS diagnosed in childhood with 4/7 hx of generalized body pain worse in the
back and lower limbs, 2/7 hx of high grade, intermittent fever and breathlessness on exertion and at rest.
There was positive hx of generalized headache and of LOC. Nil hx of seizures, vomiting, blurry vision, nil hx
of previous stroke or TIA
Nil hx suggestive of renal or hepatic decompensation.
No hx of alcohol consumption, smoking, illicit drug use, nil hx of blood transfusions , not a known diabetic or
hypertensive and no family hx of similar symptoms.
Last crisis was 18 months ago. Steady state PCV 28%
PE: unconscious, febrile, pale, icteric, tachycardia, tachypnea, spo2 90%

20. ASSESSMENT
VOC in a known HbSS r/o complicated malaria
Sepsis ? focus kiv Chest
LOC ? cause r/o CVA

21. PLAN
Admit to ICU for close monitoring and oxygenation
FBC + ESR, CRP, EUCR, LFT,
Viral markers, D-dimer, CXR
Brain CT scan, ABG
Urinalysis + mcs
HbA1c

22. IVF 0.9% N/S 500mls alt 4.3% D/S 500mls + 3cc Vit Bco in each pint 4hrly
IV Rocephin 2g stat then 2g dly
IV Metronidazole 500mg 8hrly
IV Pentazocine 30mg stat then 30mg 6hrly
IV PCM 1g stat then 900mg 8hrly
INO2 via NRFM @ 10-15L/min to target SpO2 at >94%
IM EMAL 150mg dly x3/7
Tab folic acid 5mg dly
Tab Paludrine 200mg dly
Tab Vit C 500MG bd

23. Tepid sponge/ adequate exposure PRN
Pass NG tube for feeding and medications
Pass urethral cathether
Strict Input/Output charting
Daily RBS
Close vital signs monitoring

24. AVAILABLE INVESTIGATIONS
FBC (2/1/24)
PCV 24.3%
WBC 14.5 x 109/L N 77.7% L 12.8%
PLT 110 x 103/UL
ESR 56mm/hr
Malaria thick and thick film - Negative
CXR - no abnormality seen
EUCr (2/1/24)
Na 149 mmol/l
K 3.5 mmol/l
HCO3 32 mmol/l
Cl 114mmol/l
Urea 5.4 mmol/l
Creatinine 59 umol/l

25. Consultant Review D1OA 12HRS ICU
24 yr old known HbSS diagnosed at childhood at 2yrs with poor clinic attendance who presented
with bone pain x4/7 and suddenly lapsed into unconsciousness.
Patient was transferred to the ICU and yet to do Brain CT scan since admission.
EUCr - hypernataremia (149mmol/l) and hyperchloremia (114mmol/l)
ESR- 56mm/hr
WBC - Leucocytosis of 14,500 Neutrophilia 77.7%
Thrombocytopenia (110 x 103/UL)

26. O/E
Young man, on INO2 via nasal prongs, pale, facial puffiness, afebrile, tinge of jaundice, nil pedal edema
CVS : PR - 104b/m
BP - 118/70mmHg
CNS : GCS : E 2 V 1 M 5 = 8/15
CHEST : 22cpm SPO2 =99% on O2 therapy
ASSESSMENT
? Acute Stroke in a known HbSS to r/o Chest Syndrome

27. PLAN
Toxicology screening
Urgent brain CT scan
CXR
FBC, LFT, EUCR, PBF
Serum uric acid, D-dimer, HbA1c
Consult to neurology unit to review
CT iv fkuids
Further review with brain CT scan result

28. D2OA 1DICU
FBC (3/1/24)
PCV 21.8%
WBC 14.6x 109/L N 65.3% L 28.8%
PLT 123 x 103/UL
EUCr (3/1/24)
Na 155mmol/l
K 3.5 mmol/l
HCO3 22 mmol/l
Cl 115mmol/l
Urea 38mg/dl
Creatinine 0.8mg/dl

29. D2OA 1DICU
Pt yet to do some investigations. Samples taken for blood culture and urinalysis
0/E
Young male, conscious but drowsy, pale, icteric, acyanosed, on INO2, NG tube insitu, nil pedal edema,
uretheral catheter insitu draining clear urine
CNS - Conscious
GCS - E 4 V 4 M 6 = 14/15
Tone RUL - Hypertonia RLL Normal
LUL - Normal LLL Normal
CVS : PR 73bpm
BP 139/83mmHg
CHEST : RR 24cpm
SP02 100% 02
BS Vesicular

30. PLAN
Transfuse with 1 pint of packed red cells
Ensure outstanding investigations
Commence on graded oral sips
TED stockings

31. D3OA 2DICU
24yr old male HbSS being managed as a case of Acute CVA r/o Chest Syndrome complicated by
anaemia.
Brain CT Scan images revealed no abnormality. Awaiting radiologist report
Was transfused with 1 pint of blood yesterday. Awaiting blood culture and urine mcs results
Post transfusion FBC (5/1/24)
PCV 24.6%
WBC 16.6x 109/L N 62.9% L 31.5%
PLT 218 x 103/UL

32. LFT
Total protein 5 g/dl
Albumin 3.1g/dl
Total bilirubin 1.8mg/dl
Conjugated bilirubin 0.66 mg/dl
AST 128 iu/l
ALT 41 iu/l
ALKP 363 iu/l
GGT 125iu/l

33. Hematology review
ASS : ?CVA in a HbSS male
? Chest infection
PLAN
Nurse in cardiac position
FBC
IV 4.3% D/S alt 5% D/S 6hrly
CT IV antibiotics
Invite neurologist
Patient commenced Physiotherapy of chest and limbs

34. D5OA 4DICU
Pt had been transfused with another pint of blood - total of 2 pints since admission.
Post transfusion PCV (6/1/24) = 24.9%
Repeat EUCr (6/1/24)
Na 140mmol/l
K 2.5 mmol/l ( on correction)
HCO3 23 mmol/l
Cl 104mmol/l
Urea 3.1mmol/l
Creatinine 50umol/l
eGFR 167

35. Brain CT radiologist report - No abnormality seen
Rhinosinusitis
Pt yet to do investings of ECG, D-dimer, Hba1c, toxicology screening, uric acid
O/E
CNS conscious and alert
GCS : E 4 V 5 M 6 = 15/15
CVS : PR - 92b/m
BP - 129/82 mmHg
RES : RR - 22cpm
SPO2 - 100% on 02

36. Plan
Ensure transfusion with 1 pint of packed red cells
Ensure outstanding investigations
Repeat E/U/Cr after K correction
Repeat FBC post transfusion
Retrieve report of urine mcs and blood culture