A 50 years old male with loss of consciousness
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B.Pavithra ,9th semester.
roll no;19
CASE:
date of admission:27/12/22
This is a case of 50 years old male resident of azarguda,nalgonda who is labourer came to the casualty with sudden fall and loss of consciousness on 27/12/22
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 7 days ago and then he developed loss of consciousness during his work which was sudden in onset without any aura and seizure activity.No up rolling of eye lids and frothing.
H/o blurring of vision since 4 months
H/o nocturia, polyuria and dysuria since 2 months
H/o tingling sensation in the leg occasionally.
H/o dry cough intermittently since 10 days
No h/o buring micturation,sob and pedal edema no h/o palpitations
No h/o fever ,nausea and vomiting.
SEQUENCE OF EVENTS:
10 years back he was diagnosed with type 2 diabetes mellitus and was on oral hypoglycemic agents but did not have any dietary modifications due of lack of awareness.
6 months back he was diagnosed with hypertension but he took medication for 15 days and then stopped using medication.1 month back he was diagnosed with ckd and stones as he was having back ache.for which medication were given.
Since 1 month he shifted to insulin from oral hypoglycemic agents.
7 days back he didn't take insulin and went to work where he suddenly had loss of consciousness and was bought to hsptl in nalgonda and was bought to our hsptl on 27/12/22 afternoon.
PAST HISTORY: No similar complaints in the past.No h/o asthma,tb ,epilepsy thyroid abnormalities and blood transfusions. No h/o previous surgeries.
PERSONAL HISTORY:
DIET: mixed diet
Apetite: normal
Bowel: normal
Bladder: polyuria,nocturia and dysuria
Sleep: adequate
Addictions: smoker since 35 years used to smoke 2 packets daily( beedi) but reduced to 2 beedis per day since 1 month
Occasionally takes alcohol.
Family history:
H/o diabetes to mother and died with hyperglycaemia
DRUG HISTORY:
Not significant
⁸GENERAL EXAMINATION:
Patient is conscious ,coherant,cooperative.moderatly built and moderatly nourished.
No pallor,icterus ,clubbing, cyanosis and bilateral pedal edema.
Temperature ; afebrile
RR;16cycles/min
PULSE;70bpm
GRBS;240mg/dl
Spo2; 100 at room temperature
BP; 170/90 mm of hg
SYSTEMIC EXAMINATION;
Cardiovascular system- Inspection :
Shape of chest- elliptical shaped chest
No engorged veins, scars, visible pulsations
No raised JVP.
Palpation : Apex beat can be palpable in 5th inter costal space medial to mid clavicular line.No thrills and parasternal heaves can be felt
Auscultation : S1,S2 are heard ,no murmurs.
Respiratory system:Inspection: Shape of the chest : elliptical ,B/L symmetrical ,
Both sides moving equally with respiration
No scars, sinuses, engorged veins, pulsations.
Palpation:Trachea - central
Expansion of chest is symmetrical.
Auscultation:
B/L air entry present . Normal vesicular breath sounds.
Central nervous system- Conscious, oriented to time place and person.
GCS on the day of admission was E1 V2 M4
speech : normal
Behavior : normal
Memory : Intact.
No hallucinations or delusions
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : normal
3rd,4th,6th : normal
5th : sensory intact
7th :no abnormality noted
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11th,12th : normal.
MOTOR SYSTEM EXAMINATION
Bulk of the muscle: normal
Tone of muscle : normal
POWER -
RT. LT
Upper limb 5/5. 5/5
Lower limb 5/5. 5/5
SUPERFICIAL REFLEXES :
corneal ,conjunctival ,plantar reflexes are present
DEEP TENDON REFLEXES :
BP TRI SUP KNEE ANK PLAN
RT ++ + + ++ ++ ++ Flex
LT ++ ++ ++ ++ ++ Flex
SENSORY SYSTEM EXAMINATION
SPINOTHALAMIC SENSATION
Crude touch normal
Pain normal
DORSAL COLUMN SENSATION
Fine touch normal
Proprioception normal
CORTICAL SENSATION
Two point discrimination able to discriminate
Tactile localization able to localize
CEREBELLAR SIGNS : no
Meningeal signs: no
Abdominal examination :
Inspection:on inspection abdomen is flat, symetrical,and not distended.umbilcus is centre and inverted.no scars,engorged veins are seen.All 9 regions of abdomen are equally moving with respiration.all hernial orfices are clear.
Palpation:on palpation abdomen is soft , no tenderness no other palpable organs are felt.On bimanual examination of kidney is not palpable.All inspectory findings are confirmed.
percussion:no shifting dullness, no fluid thrills.
auscultation:normal bowel sounds are heard.
PROVISIONAL DIGNOSIS:uncontrolled diabetes mellitus due to non compliance of treatment.
INVESTIGATIONS:
On 28 december 2022
Hb: 4.6 g/dl
Sr.creat:4.2
Blood urea :90
HBA1C:7.5
FBS 295 gm/dl
TGL:182
HDL 56
LDL 115
VLDL 36
ABG ANALYSIS
pH 7.332
pco2 31.5 mmHg
po2 90.4mmHg
Hco3-17.4mmol/L
On 29 december 2022::
On 30 december 2022
Hemogram:
Hb 10.4
TLC 7500
PLT 1.97
Normocytic normochromic anemia
ELECTROLYTES:
Sodium 135 mg/dl
Potassium 3.6mg/dl
Chloride 106 mg/dl
LFT:
TB 0.99
DB 0.4
AST 11
ALT 12
ALP 155
TP 4.7
ALB 2.56
ABG ANALYSIS
pH 7.37
pco2 30.2 mmHg
po2 107mmHg
Hco3-17.4mmol/L
On 31 december 2022
Hemogram:
Hb 9.8
TLC 6300
PLT 1.99
Normocytic normochromic anemia
ELECTROLYTES:
Sodium 140 mg/dl
Potassium 3.7 mg/dl
Chloride 102 mg/dl
LFT:
TB 0.67
DB 0.12
AST 12
ALT 12
ALP 195
TP 4.7
ALB 2.75
A/G RATIO 1.41
USG ABDOMEN REPORT:
Diagnosis:
Altered sensorium secondary to hyperosmolar Hyperglycemic state.
Hypertensive urgency with severe Uncontrolled hypertension with AKI on CKD
TREATMENT:
On 28 december 2022
Inj human act rapid insulin 0.1 IU/kg/hr
Continue iv infusion
Inj PAN 40 mg /IV/OD
Inj Thiamine 200 mg /100 ml NS IV/BD
Inj monocef 1gm/IV /BD
Serum potassium every 6 hrly
Vitals monitoring every 4 hrly and GRBS hrly monitoring
Inj 10%dextrose 30 ml/hr/IV
Tab amlong 5mg /RT /OD
Inj levipril 1gm /IV/Stat to
Inj levipril 500 mg in 100 ml NS/IV/BD
On 29 december 2022
Same plus no serum potassium monitoring and no thiamine
On 30 december 2022
Same plus
Inj HAR insulin TID 10 units
Inj NPH BD/IV 10 units
Syrup lactulose 30 ml /BD
On 31 december 2022
Same plus
Inj HAR 12 units TID
NPH 12 units BD
On 1 January 2023
Same like 31 december 2023
GRBS monitoring
Vitals monitoring 4th hrly
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