Final practical short case

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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

50 year old male brought to casuality with the chief complaints of altered sensorium since yesterday evening (since 15 hours).

History of one episode of vomiting yesterday morning.

History OF PRESENT ILLNESS  : 

patient was apparently asymptomatic 10years back and he developed giddiness and loss of consciousness and weakness and on routine check up he was  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

Since then the patient had abnormal behaviour , unable to identify family members, shouting and talking to self and didn't sleep the entire night and morning he had an episode of vomiting with food particles as contents, non-projectile, non-bilious.

No H/O Fever.

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

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