70 year old male with altered sensorium

 N.Deepa, 8th semester

Roll no. 93

I've 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 treatment plan. 

Following is the view of my case :  ( history as per the date of admission 9/10/21 ) 

CASE :

A 70 year old male patient was bought to the casuality with chief complaints of altered sensorium. 

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic a day before. On 8/10/21 5-6 pm he was absolutely normal and had his dinner around 7pm . Later he felt uneasiness and took a tablet GLIMI. Around 8 pm he couldn't recognize his family members, he had a staring look and gurgling sound. He had a history of fall during this episode. Later the attendees took him to local rmp where he diagnosed him with low sugar levels ( hypoglycemia) . The rmp adminstered iv fluids and gave sugar water orally. The patient became absolutely normal later. After observation for some time they went back home at 11 pm. At 4 am in the morning the attendees found that the patient had similar episode as previous and the rmp referred to our hospital. 

PAST HISTORY :

Patient is a known case of hypertension since 1 year and diabetes since 1 month. 

For hypertension - tab. TELMA 40 mg OD

For diabetes - tab. GLIMI OD

FAMILY HISTORY :

No significant family history. 

PERSONAL HISTORY :

Diet - Mixed diet

Appetite - Normal

Sleep - Adequate

Bowel and bladder movements - Regular

Allergies - No food and drug allergies

 

Addictions - alcohol occasionally

GENERAL EXAMINATION :     

On 9/10/21 when I examined

      The patient was conscious, coherent and co - operative. 

He is well oriented to time, place and person.

No pallor

No icterus

No clubbing

No cyanosis

No generalized lymphadenopathy

No bilateral pedal edema

  VITALS : 

Temperature : Afebrile

Pulse : 100 bpm

Blood pressure : 100/60 mm of hg

Respiratory rate : 20 cycles / min

Spo2 : 95%

SYSTEMIC EXAMINATION :

Cvs : S1 S2 heart sounds heard, No murmurs

Respiratory system : Bilateral air entry present. 

Cns : Intact 

Patient was aphasic at the time of presentation. 

When I was examined he regained his speech. 

Abdomen : Soft and non - tender. Bowel sounds are heard. No organomegaly. 

INVESTIGATIONS :

Usg :   raised echogenicity of kidneys on both                   sides

DIAGNOSIS :

  Altered sensorium secondary to hypoglycemia secondary to oral hypoglycemic agents. 

TREATMENT :

On 9/10/21 :

        • Nil by mouth

        • Stop oral hypoglycemics and other anti                   hypertensive drugs

        • Inj. PAN 40 mg IV /OD

        • IVF Normal saline 75 ml /hr

        • GRBS monitoring 

        • IVF - 5% dextrose 75 ml / hr

             If GRBS < 100 mg/dl

        • Strict I/ O monitoring

        • Inj. Optineuron 1 amp. in 100ml of normal           saline / IV / OD 

        • Strict BP, PR monitoring 4rth hourly

On 10/10/21 : 

         • RT feeds with 100 ml milk with 2 table                      spoon of sugar with 100ml water

         • IVF 25% dextrose 5 ml / hr 

             ( increase or decrease according to GRBS) 

         • Inj. PAN 40 mg / IV / OD

         •Strict I/ O monitoring

         • Inj. Optineuron 1 amp. in 100ml of normal           saline / IV / OD ( over 30 min)

         • GRBS monitoring hourly

         • Tab. NODOSIL 500 mg RT/ OD

         • Tab. AMLONG RT/ OD

         • Tab. SHELCAL RT / OD 

On 11/ 10 / 21 :

          • Inj. PAN 40 mg / IV / OD

         • Inj. Optineuron 1 amp. in 100ml of normal           saline / IV / OD ( over 30 min)

         • Tab. NODOSIL 500 mg RT/ OD

         • Tab. AMLONG RT/ OD

         • Tab. SHELCAL RT / OD 

         • Inj. HAI s/c according to GRBS 

                   8am - 2pm - 8pm

On 12/10/21 :

          GRBS was 190 . 

          Patient is kept on insulin. 

Patient got discharged.