70 yr old male in unresponsive state

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A 70 year old male presented to casuality in unresponsive state

K.Lasya Mithra

Roll No: 60

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 diagnosis and treatment plan.

CASE:

A 70 year old male patient was brought to causality in an unresponsive state

History of present illness:

Patient was apparently normal until 9 pm yesterday night then he went to a state of unconsciousness after eating food and started snoring. 

No H/O vomiting,  seizures, chest pain, palpitations, involuntary micturition, sweating,fever, burning micturition, giddiness,fall, trauma to head.

On presentation , patient was unconscious and his GRBS was - 33 mg/dl and he was given 25 D as bolus after which he regained consciousness  and became oriented to time, place and person.

Past history:

K/C/O DM from 6 years and not complaint to medication 

H/O focal seizures to right arm followed by weakness 2 years ago for which he was treated at local hospital. 

H/O trauma to right great toe 20 days back for which he was treated at local hospital ,inspite of which the right great toe became gangrenous. 

 Not a k/c/o of HTN, epilepsy, TB, CAD,CVD

No past surgical history

Personal history:

Appetite: Normal

Diet: Mixed

Sleep: adequate

Bowel and bladder: regular

Family history:

No significant family history

GENERAL EXAMINATION:

Patient is conscious, cohorent,cooperative and well oriented to time, place and person.

Gangrene of right great toe seen

Pallor- present

Icterus- absent

Clubbing-absent

Lymphadenopathy- absent

Cyanosis- absent

Pedal edema - absent

VITALS ON ADMISSION:

B.P:160/90 mmhg

P.R:96bpm

R.R: 16cpm

Temp:98 F

SPO2: 99%@ RA

GRBS: 33 mg/dl

SYSTEMIC EXAMINATION:

PER ABDOMEN:

Inspection - 

          Umbilicus - inverted
          All quadrants moving equally with respiration
          No scars, sinuses and engorged veins , visible pulsations. 

          Hernial orifices- free.

Palpation -  

soft, non-tender

no palpable spleen and liver

Percussion - resonant note heard

Auscultation- normal bowel sounds heard. 

CARDIOVASCULAR SYSTEM:

Inspection : 

• Shape of chest- elliptical 
• No engorged veins, scars, visible pulsations
• JVP - not elevated

Palpation :

•  Apex beat can be palpable in 5th inter costal space
• No thrills and parasternal heaves can be felt

Auscultation : 

• S1,S2 are heard
• no murmurs

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes: Right.     Left. 

Biceps.         +          +

Triceps.        +          +

Supinator     -          -

Knee.            +         +

Ankle            +       +

PROVISIONAL DIAGNOSIS:

ALTERED SENSORIUM SECONDARY TO OHA INDUCED HYPOGLYCEMIA 

RIGHT TOE GANGRENE WITH AKI ON CKD

HYPERKALEMIA (RESOLVED)

ANEMIA UNDER EVALUATION?IDA

DM - SINCE 20 YEARS

INVESTIGATIONS:

CBP:

Hb - 7.3 gm/dl

TLC -  6500 cells/ cumm

RBC - 3.85 million

PLT -  2.9 lakh

CUE:

Colour- pale yellow 

Albumin- negative

Sugars- negative 

Pus cells- 6-7 cells

Epithelial cells- 1 to 2 cells/ HPF

RFT: 

urea - 22 mg/dl

Creatinine - 0.7  mg/dl

Na  - 141 mEq/L

K - 5.2 mEq/L 

Cl - 104 mEq/L 

LFT :

TB- 0.61 mg/dl

DB- 0.16 mg/dl

ALT - 17 IU/L

AST - 28 IU/L

ALP - 264 IU/L

TP - 6.8

albumin - 2.8 gm/dl

COAGULATION PROFILE:

BT- 2.3 

CT- 4.3

PT- 14 sec 

APTT- 29 sec

INR- 1.1

ANEMIA PROFILE:

SERUM IRON -60

RETIC COUNT - 0.4 %

STOOL FOR OCCULT BLOOD - negative 

 X-RAYS:

XRAY - C SPINE (AP AMD LATERAL VIEW)

CHEST XRAY:

XRAY KNEE WITH LEG (AP AND LATERAL VIEW)

ECG:

DOPPLER OF RIGHT LOWER LIMB:

USG ABDOMEN :

2D ECHO:

REFERRALS TAKEN:

1.OPTHALMOLOGY: I/V/O diabetic retinopathy 

Fundus examination revealed cataractous lens

Advised both eyes cataract surgery

2. SURGERY: I/V/O RIGHT GREAT TOE GANGRENE

Advised ray amputation of toe after revascularisation surgery .

TREATMENT:

INJ CEFTRIAXONE 1 gm IV BD

INJ LASIX 40 MG IV BD

T ECOSPIRIN GOLD 75/75/20 PO HS

T RAMIPRIL 2.5 MG PO OD

T CARVIDIOL 3.125 MG PO OD

T OROFER XT PO OD

INJ HAI S/C ACC TO GRBS