55 yrs old male patient with cheif complaints of an episode of generalised jerky movements of upper and lower limbs 4 hours ago

-

55 year old man was rushed to the emergency room by his family with complaints of generalised jerky movements of upper and lower limbs, lasting for 2 minutes, that occurred 4 hours ago at 4 AM in the night. 

Patient was apparently asymptomatic until yesterday night, when he had sudden jerky movements of upper and lower limbs, associated with loss of consciousness and involuntary micturition back. The patient is disoriented to time, place but recognises his family, there is post ictal confusion. The patient feels tired and week. There are no signs of tongue bite or fracture of long bones. Upon further inquiry the patient gives history of consumption of alcohol (650ml) for 2 days (3 days prior to presentation) continuously, subsequently, 2 days back he  developed abdominal pain which is dragging type, localised to the right upper quadrant and associated with altered sensorium.

Review of systems revealed :-

C/o chest pain, dragging type, non radiating to left arm.

C/o vomiting 3 days back, non bilious, not projectile, with food particles as contents


Past history:-

Patient is k/c/o DM since 2 yrs and on oral hypoglycemic drugs.(Glimi M2)

Patient never had history of similar episodes in the past.

He has no history of any CAD or CVA.


Personal history:-

Alcohol consumption since 30 yrs and currently consumes 650 ml of alcohol daily.

The person has a 30 pack year smoking history. (10 beedis/day) 


On examination patient is conscious, irritable


Vitals:-

BP- 120/70 mmHg

PR-111 bpm

Spo2- 99%at RA.


GRBS- 

5:30-600

7:30- 390

8:30-380

9:30- 383

10:30- 382

11:30- 260

12:30- 210

1:30- 220

2:30- 206

3:30- 207

4:30- 147

5:30- 77

6:30- 121

7:30- 131



Clinical exam pictures :-







Systemic examination:-

CVS - S1, S2 heard, no murmurs, no JVP observed, neck veins not distended 

RS - respiratory rate - 22 cpm, no adventitious breath sounds heard 

CNS - patient is in altered sensorium, irritable and irrelevant talk; GCS - 11/15

P/A - abdomen is soft , non distended, scaphoid in shape, patient complains of pain in RUQ, liver appears to be enlarged, spleen not palpable.



Lab investigations :-










Treatment:-

1. IVF- NS- 1L for 3hrs.

2. Inj HAI 6IU IV/STAT.

3. GRBS monitoring hrly.

4.IVF-5% Dextrose if GRBS<250mg/dl.

5.Inj THIAMINE 100mg in 100 ml NS/IV/BD.

6.Inj OPTINEURON 1 amp in 100ml NS/IV/OD.


PROVISIONAL DIAGNOSIS:-

Diabetic ketoacidosis with known case of diabetes mellitus.




Day 1


S

Sensorium improved 

Abdominal pain - mild tenderness in RUQ, subjectively less than yesterday

No new episodes of seizures, vomiting, diarrhoea 

No new complaints


O

Patient is conscious, coherent, cooperative

Temp- 98.4 F

BP- 110/60 mmHg

PR- 95 bpm

RR- 20 cpm

SPO2- 98% on RA

GRBS- 130 mg/dL

CVS- S1, S2 +

RS - BAE +; Trachea- Central

P/A- Soft, non distended, mild tenderness in RUQ, BS +

CNS- sensorium improved, oriented to time place and person, GCS - 13/15


A

Diabetic ketoacidosis with known case of diabetes mellitus.


P

1. IVF- NS- 1L for 3hrs.

2. Inj HAI 6IU IV/STAT.

3. GRBS monitoring hrly.

4.IVF-5% Dextrose if GRBS<250mg/dl.

5.Inj THIAMINE 100mg in 100 ml NS/IV/BD.

6.Inj OPTINEURON 1 amp in 100ml NS/IV/OD.



Day 2


S

Sensorium improved 

no complaints of abdominal pain

No new episodes of seizures, vomiting, diarrhoea 

No new complaints


O

Patient is conscious, coherent, cooperative

Temp- 97.4 F

BP- 120/60 mmHg

PR- 88 bpm

RR- 18 cpm

SPO2- 99% on RA

GRBS- 124 mg/dL

CVS- S1, S2 +

RS - BAE +; Trachea- Central

P/A- Soft, non distended, BS +

CNS- sensorium improved, oriented to time place and person, GCS - 15/15


A

Diabetic ketoacidosis with known case of diabetes mellitus.


P

1. IVF- NS- 1L for 3hrs.

2. Inj HAI 6IU IV/STAT.

3. GRBS monitoring hrly.

4.IVF-5% Dextrose if GRBS<250mg/dl.

5.Inj THIAMINE 100mg in 100 ml NS/IV/BD.

6.Inj OPTINEURON 1 amp in 100ml NS/IV/OD.
















Comments

Post a Comment

Popular posts from this blog

PARAPARESIS OF THE LOWER LIMBS SECONDARY TO TB

-
Paraparesis of the lower limbs. Hello all, I am P.Vihar (Roll no 127) a student of 8th semester pursuing medicine at KIMS Narketpalli. Today I share, in this blog  my views and thoughts on a case   which our department of general medicine has shared, to help us achieve better understanding of the clinical cases. The link given below, is to the entire case details :- https://vaish7.blogspot.com/2020/05/medicine.html?m=1 MY VIEWS AND THOUGHTS ON THIS CASE. Here we see a 23 year old male patient with history of a sudden fall when he tried to get up to use the bathroom. Patient came to the hospital in this regard complaining of weakness in both lower limbs. After going through his history i have some questions in mind which i will write down below:- 1) His chief complaint was tingling and numbness in both lower limbs since 5 days. This makes me think of paresthesia in his legs, but when we talk about paresthesia there are many causes like herniated disc, tumor in the spinal cord, etc.. al
Read more

2023 (November) JRCPTB QIP Project Cycle - 3 Presentation.

-
Image
Inpatient care Quality Improvement Project.   The Inpatient care quality improvement cycle started with the goal of improving patient care by identifying lapses, and checking progress in 4 domains of clinical practice that impact the quality of inpatient care namely;    ·        History taking  ·        Clinical/ physical examination ·        Lab and imaging data analysis ·        Full case analysis   Using the online learning portfolios of the students of 2016 batch; which was divided into 4 quarters; these 4 domains were graded based on performance from 0-4. I collected this raw data and processed the data to represent it statistically (quarter mean and cumulative mean scores). Thus enabling us to check for progress/ changes in specific domains and overall clinical practice.   After processing the data, I systematically entered the data into an excel spreadsheet and made relevant tables/ graphs to represent our findings.  These online learning portfolios were selected for cycle 3. T
Read more

80 yr male

-
 80 yrs old Male came to casualty with  C/O loss of consciousness (for half an hour) C/O involuntary bowel and bladder incontinence and slurred speech since 4am today(19/12/21) HOPI Patient was apparently asymptomatic till 4:00am today got up from bed and walked to washroom ,while walking near the door at 4:00am,patient slipped and fell on the ground-sustained injury to back and head. He had loss of consciousness for half an hour and then regained.Conscious spontaneous with no involuntary movements,froth from mouth. H/O involuntary micturition and defecation present  H/O slurred speech present after fall On presentation patient is conscious,confused,slurred speech present. Past history  N/K/C/O HTN,DM,TB,epilepsy,CVA,CAD Personal history  Diet -mixed Appetite-normal Bowel movements-irregular  He is a toddy drinker and smokes chutta  Family history  Not significant  General examination  Pt is conscious  Vitals Temp-Afebrile  Bp-120/60mmHg PR-90bpm Spo2-99% on RA Systemic examination  CV
Read more