202304469

 

 



Case History and Clinical Findings

PATIENT WAS BROUGHT TO CASUALITY IN UNRESPONSIVE STATE.

PATIEN WAS APPARENTLY ASYMPTOMATIC 3 YEARS BACK THEN SHE DEVELOPED GENERALISED WEAKNESS FOR WHICH SHE VISITED LOCAL HOSPITAL AND WAS DIAGNOSED WITH TYPE 2 DM. SINCE THEN PATIENT WAS ON IRREGULAR MEDICATION. TODAY MORNING PATIENT ATTENDERS NOTICED THAT PATIENT WAS IN UNRESPONSIVE STATE AND WAS UNABLE TO WAKEUP FROM SLEEP AND WAS TAKEN TO LOCAL RMP (HIGH SUGARS 600 MG/DL WAS OBSERVED) AND WAS REFERRED TO OUR HOSPITAL IN UNRESPONSIVE STATE, HER GCS - E1V1M6.

NO H/O ABNORMAL MOVEMENTS, HEADACHE,VOMITING. K/C/O DM2 SINCE 3 YRS AND ON IRREGULAR MEDICATION. NOT K/C/O HTN,ASTHMA, CAD, EPILEPSY.

PERSONAL HISTORY : APPETITE - NORMAL DIET - MIXED

 

BOWEL AND BLADDER - REGULAR SLEEP - ADEQUATE

ADDICTIONS : OCCASIONAL TODDY-ONCE A WEEK TOBACCO(BEEDI) FROM 20 YEARS, STOPPED 3 YEARS AGO GENERAL EXAMINATION :

NO PALLOR, ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY,PEDAL EDEMA VITALS ON ADMISSION:

TEMP- 101 F PR-90 BPM

BP- 100/70MM HG RR- 20 CPM SPO2- 97% AT RA

GRBS - 226 MG/DL SYSTEMIC EXAMINATION:

1)    PER ABDOMEN:

INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.

PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY. ASCULTATION: BOWEL SOUNDS - HEARD 2)RESPIRATORY SYSTEM:

INSPECTION:SHAPE OF THE CHEST IS ELLIPTICAL,B/L SYMMETRICAL.BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS. PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL

IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL .VOCAL FREMITUS IS NORMAL

PERCUSSION: RESONANT B/L ASCULTATION: BAE + , NVBS HEARD

3)  CVS:

INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.

PALPATION: APEX BEAT FELT IN LEFT 5TH ICS.NO THRILLS AND PARASTERNAL HEAVES. ASCULTATION: S1S2 +,NO MURMURS

4)  CNS:

GCS - E1V1M6

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

 

NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEM- NORMAL,

MOTOR SYSTEM: TONE- NORMAL, POWER- 0/5 IN RIGHT UL AND LL , 2/5 IN LEFT UL AND LL REFLEXES : BICEPS - 1+ , TRICEPS-1+ , SUPINATOR - 1+ ,KNEE - 1+ , ANKLE - 1+

 

BRIEF COURSE IN HOSPITAL: PATIENT WAS BROUGHT TO THE CASUALITY IN UNRESPONSIVE STATE , HER GCS BEING E1V1M6 NECESSARY INVESTIGATIONS WERE DONE AND UPON EVALUATION SHE WAS FEBRILE(102 F) &HER SUGARS WERE HIGH 600MG/DL ,FOR WHICH SHE WAS TREATED ACCORDINGLY . HER C/S REPORT REVEALED ECOLI GROWTH AND WAS STARTED ON ANTIBIOTICS TO TREAT HER UROSEPSIS .PATIENT IS BEING DISCHARGED UNDER HEMODYNAMICALLY STABLE CONDITION.

 

Investigation

1) HEMOGRAM:

29/01/23

HB : 13.0 mg/dl PCV : 24.8%

TLC : 13500 CELLS/CUMM PLAT: 1.8 LAKH/CUMM 30/01/23

HB : 11.1 mg/dl PCV : 34.5%

TLC : 13400 CELLS/CUMM PLT : 1.7 LAKH/CUMM 31/01/23

HB : 10.6 mg/dl PCV: 33.1 %

TLC : 6900 CELLS/CUMM PLT : 1.7 LAKH/CUMM 01/012/23

HB : 10.8 mg/dl PCV : 33.3%

TLC : 6700 CELLS/CUMM PLT : 2.1 LAKH/CUMM

 

2) USG ABDOMEN: NO SONOLOGICAL ABNORMALITY DETECTED

3) USG NECK: TRIRADS 3 LESION IN RIGHT LOBE OF THYROID TRIRADS 2 LESION IN LEFT LOBE OF THYROID

4) BLOOD C/S : NO GROWTH SEEN

5) URINE C/S : E.COLI ISOLATED.

6) 2D ECHO : NO RWMA , CONCENTRIC LVH+ TRIVIAL TR+/MR+/AR+

NO AS, MS EF=62%

GOOD LV SYSTOLIC FUNCTION, DIASTOLIC DYSFUNCTION +, NO PE,PAH.

Treatment Given(Enter only Generic Name)

1.   VF - NS@ 75ML/HR

2. INJ.PIPTAZ 4.5 GM IV/TID

3. T NITROFURONTOIN 100 MG PO/BD

4. INJ PAN 40 MG IV OD

5. INJ KCL 20 MEQ IN 100 ML NS

6. INJ MAGNESIUM 1 AMP IN 100 ML NS

7. T DOLO 650 MG PO/TID

8. SYP POTCHLOR 10 ML PO/TID

9. INJ HAI S/C ACCORDING TO GRBS

Advice at Discharge

1.T NITROFURANTOIN 100 MG PO/BD X 3DAYS

2) T PAN 40 MG PO/OD X 3 DAYS

3. SYP POTCHLOR 10 ML PO/TID X 3 DAYS

4. T GLIMI M1 PO/BD X TO BE CONTINUED


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