75 year old woman with recent right femur neck fracture, intermittent hematuria, right ureteric hydronephrosis and HRCT screening for covid showing fibrotic nodules in right middle lobe

 

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Here is a case I have seen:

A 75 year old woman presented with complaints of Pain in the right thigh

Reduced urine output

 Reddish colored urine since 3 days

 She stays at home and has 3 children (daughters).

5 years ago, she slipped and fell down the stairs and had a laceration over her forehead for which suturing was done. She even had reduced urine output and hematuria for which she had been evaluated and was diagnosed with Hydroureteronephrosis and UTI for which she was put on medications.

3 years ago, she got diagnosed to be hypertensive and has been on Tab Stamlo 5mg. She is a known case of CKD with anemia. She also started to experience dyspnea on exertion since 3 years on and off, graudal and not progressive, it wasn't associated with cough, PND orthopnea, hemoptysis.
3 days ago, she slipped and fell at 4 am and attained right intertrochantric fracture. Since then she has been experiencing reduced urine output and also says she has been having red coloured urine.

General Examination:

The patient is conscious, coherent, and cooperative and oriented to time, place, and person.

Pallor +

When she presented to us she was on foley's inserted by an outside hospital , bright red urine could be seen through her urobag

PR - 90 bpm 

Bp - 130/70 

RR- 20 cpm

Afebrile

Cvs - S1,S2 

Lungs - Inspiratory crackles + in Right IMA , IAA

We've sent routine investigations 

We've also taken an orthopedics opinion for her right inter trochanteric fracture

                                                                                ECG

Right lung fibrotic changes are seen

Problem Assessment :

75 year old woman with

Dyspnea on exertion since 3 years

Right Intertrochanteric fracture since 3 days

Hematuria since 3 days

2Decho was adviced to rule out cardiac cause of Dyspnea

Significant albuminuria - adviced 24 hours urinary protein and creatinine

Usg abdomen showed Right HUN for which urology opinion was taken

For Right ITC fracture for which orthopedics opinion was taken

And also a throat & nasopharyngeal swab was advised keeping the covid pandemic in mind

On Day 2: 

Nasopharyngeal swab and throat swab was sent in the morning.

Skin traction to be done as advised by the orthopedics department.

Urology opinion was taken and NCCT KUB was advised

Gynecology opinion was taken to rule out causing cervical and vaginal causes of hematuria. .

On Gynecological evaluation: There is no mass in the abdomen. Since she could not be put in Lithotomy position gynecological examination was not done.

Day 3:

Her swab report came out to be negative

Her Spot urine creatinine  ratio was 0.48

24 hour urinary protein report awaited

Her sputum sample was sent for cultures and for AFB

Her long standing dyspnea on exertion was because of LAD territory ischaemia

She has also been complaining of productive cough since 2 days 

Orthopedics department advised for derotation boot for her right lower limb.

Her diagnosis :

LAD ISCHAEMIA

RIGHT ITC FRACTURE

RIGHT LUNG PNEUMONIA

HYPOALBUMINAEMIA

RENAL FAILURE WITH ANEMIA OF CHRONIC DISEASED

Day 4:

Ward 15

75yr old women

Rt IT fracture

Rt lung pneumonia

CKD with Hydronephrosis

ACD

LAD territory hypokinesia

HTN since 3yrs

Pain at fracture site reduced, feeling better, no fever spikes 

I/0 2600/1700

O/E pallor +

PR 96

BP 130/80

Skin traction intact

Cvs:s1 s2+ 

RS  fine crepts +in rt IAA

Abdomen soft non tender

Under C arm: greater trochanteric fracture seen

Plan of ortho people  ORIF with PFN or DHS

1unit prbc transfusion was done yesterday. Hemogram sent today report awaited. 

Review 2d echo, cardiology fitness and physician fitness to be done. 

Patient attendors are explained about the need for 3donors.

POD 1:

75 year old women

Right It fracture

Pod - 1 ORIF with DHS(right)

No fresh complaints, no fever spikes

I/O:1300/900

PR :88/min

BP:100/70

RR:20 cpm

Sp O2 :92%on room air

Cvs:s1 s2+, no murmurs

Rs:BAE+, fine crepts in right IAA. 

PA:soft, NT

CNS:No FND

L/E:drain insitu

No soakage

Distal pulses felt

Active ankle and toe movements present

Intraoperatively:

Inj. 0.5% bupivacaine 

Inj. fentanyl were given

OT notes:

Pre-operative diagnosis: Right IT fracture

Surgery proposed: ORIF and DHS on the right side

Procedure consent: yes

Blood transfusion consent: yes

Medical or Cardiology clearance: yes

Surgery executed: ORIF and DHS on right side

Implants used: 5 holed DHS, 80 mm Lag screw

Type of procedure: major

Anesthesia: CSE

Time of starting: 12:40 pm

Time of completion: 5:15 pm

Operative procedure: The patient is in combined spinal epidural anesthesia on traction table fracture reduced on traction and internal rotation. A 20 cm incision was given on lateral aspect of right thigh. 100 ml of serous discharge was drained and sent for culture and sensitivity and tissue was sent for biopsy. The fracture site was identified and reduced with the help of bone spikes and there was severe comminution of Greater trochanter and bone loss over the superolateral aspect of the neck of femur. A guide wire was passed into the head of femur in center to center position, triple rearing was done over the guide wire. Then, the 80 mm lag screw was inserted, 140 degrees DHS barrel plate was inserted, reduced to the shaft and fixed with 5 appropriate sized cortical screws. Then, thorough wound wash was given. G bone was inserted into the bone defect and greater trochanter was sutured. The wound was closed in layers over a drain. Sterile dressing was applied and the patient was shifted to post-op in stable condition.   

Post op:

NBM till 11:30 pm

IVF NS/RL @80 ml/hr

Inj magnex forte 1.5gm IV BD

Inj metrogyl 100ml IV TID

Inj neomol 100 ml IV TID

Inj Pan 40 mg IV OD

Inj Tramadol 50 mg IV in 100 ml NS SOS for pain

Tab Chymoral forte TID after NBM break

1unit PRBC was transfused intraop. 

1unit PRBC was transfused on POD 1.