“This is an online e log book to discuss our patient’s de- identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence based inputs. This e-log book reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.”
Date of admission:04-02-2022
50 YEAR OLD MAN WITH ALTERED SENSORIUM
-
50 year old man presented to the casuality with a chief complaint of altered sensorium since 3 days.
History of one episode of vomiting on morning of Feb 3rd.
Patient was apparently asymptomatic 12 years back and then he developed giddiness and weakness.On routine checkup, he was diagnosed with diabetes.
4 months back, patient had an injury to right foot with small ulcer initially and then it progressed leading to amputation of three toes of right foot.
On Feb 3rd, patient went to his brother's house for party and had a meal of mutton curry along with 6 units of whiskey and he skipped a dose of OHA.
Since then the patient had abnormal behaviour with vomiting 1 episode - food particles as contents, non-projectile, non-bilious
No H/O Fever.
PAST HISTORY:
K/C/O DM since 12 years on T.GLIMINYL-MP2 BD.
Amputation of last 3 toes of right foot 4 months ago.
No H/o Hypertension
No H/o Asthma
No H/o Epilepsy
PERSONAL HISTORY:
Diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movements- regular
Occasional alcohol intake +
FAMILY HISTORY: Not significant
TREATMENT HISTORY:
The patient is on T.GLIMINYL-MP2 BD since 12 years for diabetes.
No known drug allergies.
GENERAL EXAMINATION:
Patient was conscious,and co-operative but has a trouble understanding and answering the questions asked.
Built:Well-built
Nourishment: Well nourished
-Pallor +
-No clubbing
-No cyanosis
-No icterus
-No generalized lymphadenopathy
-No pedal edema
Mild dehydration +
No neck stiffness
Kernig and Brudzinski sign negative
VITALS:
Temp.- Afebrile
PR- 91 bpm
RR- 24 cpm
BP- 220/110 mmHg
SpO2- 97% at RA
GRBS- 524 mg/dL
SYSTEMIC EXAMINATION:
CVS: S1S2 heard, no murmurs
RS: BAE+ NVBS+
P/A: Soft, Non-tender.
CNS:
Patient is drowsy but arousable
Incoherent speech
Motor and sensory systems - could not be examined
Reflexes - could not be elicited
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
Uncontrolled sugars with altered sensorium secondary to ?DKA
TREATMENT:
1. IVF - NS @ 125 ml/hr continuous IV
2. Inj. HAI 6U IV STAT
3. Inj. Thiamine 2 amp in 100 ml NS IV STAT followed by Inj. Thiamine 1 amp in 100 ml NS IV/OD
4. Inj. Zofer 4 mg IV SOS
5. Inj. Lorazepam 1 ml in 4 ml NS @ IV STAT
6. Inj. Monocef 1 gm IV BD
7. Foley's catheterisation
8. Tab. Nicardia 10 mg PO STAT
9. Vitals monitoring 4th hourly
10. GRBS monitoring every hour.
Psychiatry opinion was taken i/v/o alcohol withdrawal (? intoxication) and patient was diagnosed as delirium due to ? DKA as well as alcohol withdrawal and was advised:
1. Inj. Haloperidol 1/2 ampoule(0.5 ml) 2.5 mg IM STAT
2. Inj. Lorazepam 2 mg (1/2 ampoule) 1 ml IM SOS (if patient is anxious/irritable) after informing
3. Dim lighting
4. Orientation cues
5. Adequate hydration
6. Correct the underlying cause
Comments
Post a Comment