A CASE OF ALTERED SENSORIUM PRESENTED IN SPRING 2022

                                                                      NOTE:

  • The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent.
  • Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
  • This E-log also reflects my patient's 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 competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and providing treatment best to our skills and wisdom.

A 50 YEARS OLD MALE PRESENTED IN CASUALITY WITH COMPLAINTS OF ALTERED SENSORIUM

CHIEF COMPLAINTs

➤Altered sensorium since yesterday evening

➤Not able to recognize his family members since yesterday evening

➤Shouting and aggressive behavior since yesterday evening

➤Irrelevant talks and blabbering since yesterday evening

➤1 episode of vomiting on day of admission

HISTORY OF PRESENTING ILLNESS

Patient was apparently normal 10 years back then he developed giddiness and weakness. On routine checkup he was diagnosed to be diabetic. 1yr back his left toes got burnt by silencer which progressively developed into ulcer and got infected. 4 months back  last 3 toes of left leg got amputated. After surgery patient was advised to leave alcohol and so he did and was put on insulin. 1 month back he was again shifted back to oral hypoglycemic agents .Going against medical advise he again started taking alcohol but in lower quantity like once in 2 days. 

Now yesterday patient went to his brother in law and had mutton with 90 ml of whiskey .after returning to home he doesn't called his wife as usual rather started irrelevant talks ,shouting to self and was not able to recognize his family members. Entire night he was restless and skipped evening OHA dose. Next morning patient had vomiting 1 episode: food particles as contents ,non projectile, non bilious with no h/o fever and no neck stiffness.

HISTORY OF PAST ILLNESS 

➤k/c/o DM 10 years

➤Amputation of last 3 toes of left toe

➤Not k/c/o hypertension, bronchial asthma, epilepsy.

DRUG HISTORY

➤Tab. Glimi-m BD for diabetes

PERSONAL HISTORY

➤Patient is married

➤Patient takes mixed diet with normal appetite.

➤Bowel and bladder movement is normal and regular.

➤Intake of Alcohol  occasional 15-20yrs

FAMILY HISTORY 

➤No significant family history.

GENERAL EXAMINATION 

➤Pallor : Seen

➤Icterus :  Not seen

➤Cyanosis :  Not seen

➤Clubbing :  Not seen

➤Lymphadenopathy :  Not seen

➤Edema :  Not seen

➤Dehydration: Mild

VITALS

➤Temperature : Afebrile

➤PR : 91beats per minute

➤BP : 220/100 mmHg

➤RR : 24 cycles per minute

➤SpO2 : 97% at room air

➤Blood Sugar (random) : 524mg/dl


SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM EXAMINATION

➤s1 and s2 heard

➤Thrills absent

➤No cardiac murmurs

RESPIRATORY SYSTEM

➤Normal vesicular breath sounds heard.

➤Bilateral air entry present


ABDOMINAL EXAMINATION

➤ SOFT ,NT

CENTRAL NERVOUS SYSTEM EXAMINATION

➤Conscious but Drowsy

➤Incoherent

➤Not oriented to time, place and person

PROVISIONAL DIAGNOSIS : ALTERED SENSORIUM SECONDARY TO                                                                           DKA


TREATMENT

DAY 1

➤TVF NS @125ML/HR CONTINUIOUS IV

➤INJ HAI 6U/IV/STAT

➤INJ THIAMINE 2AMP IN 100ML NS/IV/STAT

➤INJ ZOFER B4MG/IV/SOS

➤INJ LORAZEPAM 1ML IN 4ML NS@ IV STAT

➤TAB NICARDIA

➤BP/PR/TEMP MONITORING 4TH HRLY

➤GRBS MONITORING EVERY HOURLY

➤FOLEYS CATHETERISASTION






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