Case 30 - 55 yrs old male patient with cheif complaints of an episode of generalised jerky movements of upper and lower limbs 4 hours ago

 A 55 year old man was rushed to the emergency room by his family with complaints of generalised jerky movements of upper and lower limbs, lasting for 2 minutes, that occurred 4 hours ago at 4 AM in the night. 

Patient was apparently asymptomatic until yesterday night, when he had sudden jerky movements of upper and lower limbs, associated with loss of consciousness and involuntary micturition back. The patient is disoriented to time, place but recognises his family, there is post ictal confusion. The patient feels tired and week. There are no signs of tongue bite or fracture of long bones. Upon further inquiry the patient gives history of consumption of alcohol (650ml) for 2 days (3 days prior to presentation) continuously, subsequently, 2 days back he  developed abdominal pain which is dragging type, localised to the right upper quadrant and associated with altered sensorium.

Review of systems revealed :-

C/o chest pain, dragging type, non radiating to left arm.

C/o vomiting 3 days back, non bilious, not projectile, with food particles as contents


Past history:-

Patient is k/c/o DM since 2 yrs and on oral hypoglycemic drugs.(Glimi M2)

Patient never had history of similar episodes in the past.

He has no history of any CAD or CVA.


Personal history:-

Alcohol consumption since 30 yrs and currently consumes 650 ml of alcohol daily.

The person has a 30 pack year smoking history. (10 beedis/day) 


On examination patient is conscious, irritable


Vitals:-

BP- 120/70 mmHg

PR-111 bpm

Spo2- 99%at RA.


GRBS- 

5:30-600

7:30- 390

8:30-380

9:30- 383

10:30- 382

11:30- 260

12:30- 210

1:30- 220

2:30- 206

3:30- 207

4:30- 147

5:30- 77

6:30- 121

7:30- 131



Clinical exam pictures :-







Systemic examination:-

CVS - S1, S2 heard, no murmurs, no JVP observed, neck veins not distended 

RS - respiratory rate - 22 cpm, no adventitious breath sounds heard 

CNS - patient is in altered sensorium, irritable and irrelevant talk; GCS - 11/15

P/A - abdomen is soft , non distended, scaphoid in shape, patient complains of pain in RUQ, liver appears to be enlarged, spleen not palpable.



Lab investigations :-










Treatment:-

1. IVF- NS- 1L for 3hrs.

2. Inj HAI 6IU IV/STAT.

3. GRBS monitoring hrly.

4.IVF-5% Dextrose if GRBS<250mg/dl.

5.Inj THIAMINE 100mg in 100 ml NS/IV/BD.

6.Inj OPTINEURON 1 amp in 100ml NS/IV/OD.


PROVISIONAL DIAGNOSIS:-

Diabetic ketoacidosis with known case of diabetes mellitus.




Day 1


S

Sensorium improved 

Abdominal pain - mild tenderness in RUQ, subjectively less than yesterday

No new episodes of seizures, vomiting, diarrhoea 

No new complaints


O

Patient is conscious, coherent, cooperative

Temp- 98.4 F

BP- 110/60 mmHg

PR- 95 bpm

RR- 20 cpm

SPO2- 98% on RA

GRBS- 130 mg/dL

CVS- S1, S2 +

RS - BAE +; Trachea- Central

P/A- Soft, non distended, mild tenderness in RUQ, BS +

CNS- sensorium improved, oriented to time place and person, GCS - 13/15


A

Diabetic ketoacidosis with known case of diabetes mellitus.


P

1. IVF- NS- 1L for 3hrs.

2. Inj HAI 6IU IV/STAT.

3. GRBS monitoring hrly.

4.IVF-5% Dextrose if GRBS<250mg/dl.

5.Inj THIAMINE 100mg in 100 ml NS/IV/BD.

6.Inj OPTINEURON 1 amp in 100ml NS/IV/OD.



Day 2


S

Sensorium improved 

no complaints of abdominal pain

No new episodes of seizures, vomiting, diarrhoea 

No new complaints


O

Patient is conscious, coherent, cooperative

Temp- 97.4 F

BP- 120/60 mmHg

PR- 88 bpm

RR- 18 cpm

SPO2- 99% on RA

GRBS- 124 mg/dL

CVS- S1, S2 +

RS - BAE +; Trachea- Central

P/A- Soft, non distended, BS +

CNS- sensorium improved, oriented to time place and person, GCS - 15/15


A

Diabetic ketoacidosis with known case of diabetes mellitus.


P

1. IVF- NS- 1L for 3hrs.

2. Inj HAI 6IU IV/STAT.

3. GRBS monitoring hrly.

4.IVF-5% Dextrose if GRBS<250mg/dl.

5.Inj THIAMINE 100mg in 100 ml NS/IV/BD.

6.Inj OPTINEURON 1 amp in 100ml NS/IV/OD.

Comments

Post a Comment

Popular posts from this blog

14/M, massive splenomegaly

Image
This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect current best evidence based input This Elog also reflects my patient centered online learning portfolio. I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan CONSENT AND DEIDENTIFICATION :  The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever . Case history : 14 yr old male ca
Read more

Case 32 : 47 year old male with fever ,headache and altered sensorium

Image
  47 year old male with fever ,headache and altered sensorium   March 26, 2022  thanks DR. Divya raju (intern) CHIEF COMPLAINTS : Patient came to the hospital with the chief complaints of - fever , headache , altered talking ,walking n confusion. HOPI : Patient was apparently asymptomatic 5days back .Then developed-  High grade fever with chills, intermittent in nature, relieved on medication and was associated with  headache. Altered sensorium since 2 to 3 hours (not talking and not working properly). No urine output since morning on 24-3-22 No history of  burning micturition,  vomiting, loose stools,  SOB,  cough ,chest pain, bleeding manifestations. pERSONAL HISTORY: Diet- mixed Appetite- decreased since 3 days Sleep - indequate Bowel - regular Bladder - decreased urine output on 24-3-22 PAST HISTORY : N/K/C/O DM ,HTN,BA,TB, CVA,CAD, epilepsy ADDICTIONS: Smokes ,montly once and was a occasional drinker but stopped 1 month back. No significant drug history FAMILY HISTORY  : not signi
Read more

case 1 : A 41y old man with altered sensorium

Image
  A 41y old man with altered sensorium September 02, 2020 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 also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome. Here is a case i have seen :  A 41yr old man  who is a farmer came with complaints of pain abdomen and vomitings since one day Patient was apparently alright 2 days back later he had pain abdomen following an acute binge of alcohol(750ml of local liquor) in epigastric region, colicky type,non progressive, non radiating,Which got relieved on taking food He had vomitings-2 episodes, non bilious,non projectile,conte
Read more