medicine e blog by NIKITHA
CBBLE UDHC SIMILAR CASES
Feb 6,2022
A 50 year male farmer ,manual labourer,brought to casualty with h/o altered sensorium since 1 day
H/o fever since 4 days.
HISTORY OF PRESENTING ILLNESS -
Patient was apparently asymptomatic 4 days ago,then he developed fever which is high grade,No diurnal variation, associated with chills.
No h/o cough and GE symptoms.
Attenders tells h/o stoppage of OHA for 3days, h/o decreased intake of food as he has fever.
H/o altered sensorium since 1 day.
Irrelevant talk,not recognising attenders since this morning .
Able to move all four limbs,No h/o vomitings, head ache, seizures.
Took him to nalgonda hospital, TLC-13,000:POT-5.0:CREATININE:2.9
SHIFTED HERE FOR FURTHUR MANAGEMENT.
PAST HISTORY -
H/o TB 2YRS back used ATT for 6 months.
Diagnosed as Type -2 Diabetes mellitus on OHA 1 YR back.
No H/O HTN,CVA,CAD,COVID-19.
PERSONAL HISTORY :
DIET - MIXED,
APPETITE -NORMAL ,
BOWEL MOVEMENT - REGULAR ,
BLADDER MOVEMENTS - REGULAR, ADDICTIONS-H/O SMOKING 30yrs ago(1 pack per day)-
ALCOHOL-REGULAR INTAKE OF 180ML SINCE 30YRS,STOPPED SINCE 2YRS AFTER DIAGNOSIS OF TB.
RECENTLY ALCOHOL INTAKE ON JAN 15,2022.
FAMILY HISTORY:Non-significant.
TREATMENT HISTORY: on OHA SINCE 1YS.
ON ATT FOR 6MONTHS.
ON EXAMINATION -
PATIENT IS CONCIOUS , INCOHERENT NON COOPERATIVE
NO ICTRUS
NO PALLOR
CLUBBING:present.
NO CYANOSIS , NO LYMPHADENOPATHY, NO EDEMA
VITALS -
TEMPERATURE - 97' F
PULSE RATE - 126BPM
BLOOD PRESSURE - 190/80 MM OF HG
RESPIRATORY RATE - 28
SPO2 - 97 % AT ROOM AIR
GRBS-HIGH.
SYSTEMIC EXAMINATION -
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM :
BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
DYSPNOEA PRESENT.
P/A - soft,non tenderness
, no organomegaly
CNS:
Pt is conscious, inorientation ,non cooperative
HMF: couldnot be elicited.
Motor system:unable to move right LL against gravity.
Tone - Rt Lt
U/L N N
L/L ?HYPO N
Reflexes:
Biceps,triceps,supinator,knee,ankle:can't be elicited.
B/L PLANTAR EXTENSION PRESENT.
O/E NECK STIFFNESS PRESENT,APPEARS TO BE ?SPONDYLOARTHROPATHY.
INVESTIGATIONS:
On 6/2/22
TREATMENT :
1.IVF 2 UNITS NS IV_BOLUS/STAT.
AND THEN IVF NS@100ML/HR
2.INJ.HAI 6U/IV/STAT
3.INJ.HUMAN ACTRAPID 1ML(40U)
4.INJ.THIAMINE 1AMP IN 100ML NS/IV/OD
5.INJ.OPTINEURON 1 AMP IN 100ML NS/IV/OD
6.GRBS MONITORING-EVERY HOURLY.
7.INJ.MONOCEF 2GM/IV/BD.
LP WAS TRIED AT 1:00AM BUT UNABLE TO TAKE CSF SAMPLES AS PATIENT WAS UNCO-OPERATIVE.
Day-1 SOAP NOTES:
7/2/22
S-PATIENT IS IN ALTERED SENSORIUM.
O-PATIENT IS CONCIOUS , INCOHERENT NON COOPERATIVE
NO ICTRUS
NO PALLOR
CLUBBING:present.
NO CYANOSIS , NO LYMPHADENOPATHY, NO EDEMA
VITALS -
TEMPERATURE - 98.5 F
PULSE RATE - 87BPM
BLOOD PRESSURE - 150/90 MM OF HG
RESPIRATORY RATE - 20
SPO2 - 99 % AT ROOM AIR
GRBS-222mg/dl
SYSTEMIC EXAMINATION -
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM :
BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
DYSPNOEA PRESENT.
P/A - soft,non tenderness
, no organomegaly
CNS:
Pt is conscious, inorientation ,non cooperative
HMF: couldnot be elicited.
Motor system:unable to move right LL against gravity.
Tone - Rt Lt
U/L N N
L/L ?HYPO N
Reflexes:
Biceps,triceps,supinator,knee,ankle:can't be elicited.
B/L PLANTAR EXTENSION PRESENT.
O/E NECK STIFFNESS PRESENT,APPEARS TO BE ?SPONDYLOARTHROPATHY.
A-ALTERED SENSORIUM 2°to DKA
P-LP PROCEDURE
1.IVF 2 UNITS NS IV_BOLUS/STAT.
AND THEN IVF NS@100ML/HR
2.INJ.HAI 6U/IV/STAT
3.INJ.HUMAN ACTRAPID 1ML(40U)
4.INJ.THIAMINE 1AMP IN 100ML NS/IV/OD
5.INJ.OPTINEURON 1 AMP IN 100ML NS/IV/OD
6.GRBS MONITORING-EVERY HOURLY.
7.INJ.MONOCEF 2GM/IV/BD
Serum creatinine:2.9
S.electrolytes:Na-142,k-4.1 ,Cl-96
Serum urea-60
Serum osmolarity:316.8
CBP:Hb:11.2
TLC:12,400
N/L/E/M:84/10/4/2
PLT:2.0
Day-2 SOAP NOTES
On 8/2/22ICUCASE UPDATES-BED-6
8/2/22
55YEAR/male
S-C/O ALTERED SENSORIUM-RESOLVED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema
Temp:Afebrile
PR:80bpm
BP:120/80 mm of hg
RR:20cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:SOFT,NONTENDER
A-HHS WITH DIABETIC NEPHROPATHY
P-
1 IVF NS @ UO+75 ML/HR
2.INJ HAI S/C ACC TO GRBS
3.INJ PAN 40 MG/IV/BD
4.INJ THIAMINE 1AMP IN 100MLNS/IV/OD
5 INJ MONOCEF 1GM/IV/BD
6.TAB PCM 650 MG /PO/TID
7.GRBS MONITORING 4TH HOURLY
Day-3 (9/2/22)
FBS:137
ICU CASE UPDATES-BED-6
55YEAR/male
S-C/O ALTERED SENSORIUM-RESOLVED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema
Temp:Afebrile
PR:98bpm
BP:150/100 mm of hg
RR:20cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:SOFT,NONTENDER
A-HHS WITH DIABETIC NEPHROPATHY
P-
1 IVF NS @ UO+75 ML/HR
2.INJ HAI S/C ACC TO GRBS
3.INJ PAN 40 MG/IV/BD
4.INJ THIAMINE 1AMP IN 100MLNS/IV/OD
5 INJ MONOCEF 1GM/IV/BD
6.TAB PCM 650 MG /PO/TID
7.GRBS MONITORING 4TH HOUR
Day-4 soap notes
10/2/22
55YEAR/male
S-C/O ALTERED SENSORIUM-RESOLVED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema
Temp:Afebrile
PR:98bpm
BP:150/100 mm of hg
RR:20cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:SOFT,NONTENDER
A-HHS WITH DIABETIC NEPHROPATHY
P-
1 IVF NS @ UO+75 ML/HR
2.INJ HAI S/C ACC TO GRBS
3.INJ PAN 40 MG/IV/BD
4.INJ THIAMINE 1AMP IN 100MLNS/IV/OD
5 INJ MONOCEF 1GM/IV/BD
6.TAB PCM 650 MG /PO/TID
7.GRBS MONITORING 4TH HOUR
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