A 58 year old patient

 A 58 year old patient came to the OPD with the chief complaints of fever and loss of appetite since 4 days and he is unresponsive since 2 hours

Patient was asymptomatic one month ago and then he had sudden onset left UL &LL weakness associated with deviation of mouth to right side admitted in hospital for a week and got discharged

Patient was c/c/c from then until today (20/7)21) 7:30 pm when he suddenly became unresponsive and was brought to our casuality at 8.30 pm in a state of unresponsiveness with GCS E1V1M1.

H/o fever - high grade , intermittent , associated with chills , releived with medication

Vomiting 2 episodes which was black in colour 4 days ago.

No h/o headache,seizures,cough or cold.

No other complaints

Patient continued to take OHA inspite of not taking food.

Past history: 

Known case of type 2 diabetes mellitus since 10 months and on treatment with glimi 2mg + metformin 500 mg and voglibose 0.2mg

Hypertension since one month and on telma 40mg OD

Personal history :

Diet - mixed

Appetite - decreased

Bowels - irregular

Micturition - normal

No allergies

Alcohol - occasional

Tobacco every day

General examination :

Patient is stuporous

Pallor ,icterus, cyanosis, lymphadenopathy,clubbing , oedema absent

Temperature  102 

Bp :180/110 mg/dl

Respiratory rate: 21cpm

Grbs : 14mg/dl

Pulse rate : 153 bpm

CNS Examination :

Patient  drowsy but arousable

GCS : E1V1M1

Tone :.                 right      left

Upper limb       normal.    Decreased

Lower limb      normal.      Decreased

Power               

Upper limb      4/5.               1/5

Lower limb.      4/5.               1/5

Reflexes :

B           ++.            ++

T         ++.            ++

S.         ++.             ++

K.         ++.            +++

 A         +.              ++

P.          M.             M


Cvs :

S1 S2 heard ,no murmurs


Respiratory system :

Bilateral air entry present 

NVBS


Per abdomen : 

Soft, non tender


Provisonal diagnosis :

Altered sensorium secondary to hypoglycemia

OHA induced (sulfonylureas)

Akd on CKD ? Diabetic nephropathy ?

Hyperkinetic movement secondary to metabolic cause

Known case of cva ( secondary hemiparesis)

Known case of  hypertension and diabetes mellitus

Viral hepatitis ?

Investigations :

Chest X ray :


CUE smear : 




Hemogram , rft,lft,serum electrolytes, bleeding time and clotting time :







2D echo  report screening :

Ultrasound :





 


Treatment :

Day 1 :

1. IVF 25 % dextrose continous infusion @ 100ml/hr(target grbs 125 mg/dl)

2. Inj optineuron in 500 ml Ns/iv/od

3.inj pan 40 iv/OD

4. Protein Powder Dm 2 tpsp in 100 ml milk / RT 2nd hourly

5. Grbs charting hourly

6. Monitor bp,pr,spo2 4th hourly

7.ivf 0.9 % NS RL DNS continous infusion 50ml /hr

8. Inj augementin 625 mg IV/bd

9. Rt feeds 100ml milk with sugar 2nd hourly

10. Syp lactulose 15ml tid


Day 2 :

. IVF 25 % dextrose continous infusion @ 100ml/hr(target grbs 125 mg/dl)

2. Inj optineuron in 500 ml Ns/iv/od

3.inj pan 40 iv/OD

4. Protein Powder Dm 2 tpsp in 100 ml milk / RT 2nd hourly

5. Grbs charting hourly

6. Monitor bp,pr,spo2 4th hourly

7.ivf 0.9 % NS RL DNS continous infusion 50ml /hr

8. Inj augementin 625 mg IV/bd

9. Rt feeds 100ml milk with sugar 2nd hourly

10. Syp lactulose 15ml tid

11. Tab baclofen 5mg tid

12. Tab aspirin 75mg /OD

13. Tab colanzepam 0.5mg H/S/RT

14. Inj lasix 40mg bd


Day 3 :

IVF 25 % dextrose continous infusion @ 100ml/hr(target grbs 125 mg/dl)


2. Inj optineuron in 500 ml Ns/iv/od


3.inj pan 40 iv/OD


4. Protein Powder Dm 2 tpsp in 100 ml milk / RT 2nd hourly


5. Grbs charting hourly


6. Monitor bp,pr,spo2 4th hourly


8. Inj augementin 625 mg IV/bd


9. Rt feeds 100ml milk with sugar 2nd hourly


10. Syp lactulose 15ml tid


11. Tab baclofen 5mg tid


12. Tab aspirin 75mg /OD


13. Tab colanzepam 0.5mg H/S/RT

Day 4
1.IVF 25 % dextrose continous infusion @ 100ml/hr(target grbs 125 mg/dl)

2. Inj optineuron in 500 ml Ns/iv/od

3.inj pan 40 iv/OD

4. Protein Powder Dm 2 tpsp in 100 ml milk / RT 2nd hourly

5. Grbs charting hourly

6. Monitor bp,pr,spo2 4th hourly

7.ivf 0.9 % NS RL DNS continous infusion 50ml /hr

8. Inj augementin 625 mg IV/bd

9. Rt feeds 100ml milk with sugar 2nd hourly

10. Syp lactulose 15ml tid 

11 tab. Aspirin 75mg OD

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