Final practical short case

Feb 08,2022


 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.
RECENTLY ALCOHOL INTAKE ON JAN 15,2022.
FAMILY HISTORY:Non-significant.
TREATMENT HISTORY: on OHA SINCE 1YS.
ON ATT FOR 6MONTHS.
 
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

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.

Motor system:unable to move right LL against gravity.


Reflexes:
Biceps,triceps,supinator,knee,ankle:can't be elicited.
    
B/L PLANTAR EXTENSION PRESENT.
INVESTIGATION


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
7.INJ.MONOCEF 2GM/IV/BD.







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