Final exam long case
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan
A 50 year old Male patient presented to the opd with chief complaints of :
Loss of consciousness and altered speech and movements since 15 hours
And also with a history of one episode of vomiting on the next day morning
HISTORY OF PRESENT ILLNESS :
patient was apparently asymptomatic 10vyears back and he developed giddiness and loss of consciousness and weakness and on routine check up he is diagnosed with diabetes
And on regular medication with Tab. Glimipride bd and has control over sugar levels
4 months back patient developed ulcers on his right foot due to a small accident . The ulcers are non healing and are spreading so he got his toes amputated .
4 days back he went to his relatives house and had a heavy lunch with non veg and also had 90ml of alcohol on that day and missed his medication of glimipride on that day
As there is a history of one episode of vomiting it is containing of food particles and it is non projectile and non bilious in nature
PAST HISTORY :
K/C/O DM since 10 years on T.GLIMI-M BD
He takes alcohol occasionally since 15-20 years - occasionally consumes 3-6 units of whiskey
Amputation of last 3 toes of right foot .
No H/O of hypertension
No h/o asthma
No h/o epilepsy
FAMILY HISTORY:
No relevant family history is seen in family members
PERSONAL HISTORY:
Diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movements- regular
Occasional alcohol intake +
No known allergies
GENERAL EXAMINATION:
Patient is conscious, cooperative but respondes late to the questions asked
GCS : E4V3M6
Pallor +
No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema
Mild dehydration +
No neck stiffness
Kernig and Brudzinski sign negative
Vitals at admission:
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 - couldnot 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
Patient due to his altered sensorium during to alcohol withdrawal? And DKA was suggested to a psychiatrist
For which he got medications of
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
On 5th
Patient gradually recovered from his altered sensorium on the next day in which he is drowsiness and unresponsiveness
Temp:Afebrile
PR:90bpm
BP:110/70 mm of hg
RR:26cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:Soft,non tenders
TREATMENT
.1. Ivf Ns@125ml/hr
2.Inj PAN 40 MG/IV/OD
3.INJ SODIUM BICARBONATE 50 MCG/IV/STAT
F/B INJ SODIUM BICARBONATE 100 MCG IN 400ML/NS/IV OVER 4 HOURS
4.INJ OPTINEURON 1AMP IN 100 ML NS/IV/OD
5.INJ PIPTAZ 4.5 GM/IV /STAT
F/B INJ PIPTAZ 2.25 GM /IV/TID
6.FOLEYS AND RYLES TUBE PLACEMENT
7.VITALS MONITORING
On 6th
Patient is drowsy and respond well to oral commands
Temp:Afebrile
PR:66bpm
BP:110/80 mm of hg
RR:23cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:Soft,non tender
1.IVF Ns@100ml/hr
2.INJ THIAMINE 1amp in 100 ml NS/IV/OD
3.INJ ZOFER 4MG/IV/SOS
4.INJ MONOCEF 1GM/IV/BD
5.INJ LORAZEPAM 1/2 amp IV/SOS
6.INJ HAI S/C ACC TO GRBS
7.TAB QUETIAPINE 25 MG OD
8.OINT THROMBOPHOBE L/A
9.OINT T-BACT L/A
On 7th
Patient is awake and responds well to the commands
Temp:102.3 F
PR:76bpm
BP:110/70 mm of hg
RR:20cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:Soft,non tender
1.IVF Ns@100ml/hr
2.INJ THIAMINE 1amp in 100 ml NS/IV/OD
3.INJ ZOFER 4MG/IV/SOS
4.INJ MONOCEF 1GM/IV/BD
5.INJ LORAZEPAM 1/2 amp IV/SOS
6.INJ HAI S/C ACC TO GRBS
7.TAB QUETIAPINE 25 MG OD
8.OINT THROMBOPHOBE L/A
9.OINT T-BACT L/A
10.TAB PARACETAMOL 650 MG
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