Short case - Final



 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 



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.


FAMILY HISTORY:Non-significant


 

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.


        


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:












 



PROVISIONAL DIAGNOSIS:CASE OF ALTERED SENSORIUM SECONDARY TO DKA.


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.



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