New Admission
Unit-5
ICU Bed 6
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THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT .
50 year old male brought to casuality with the chief complaints of altered sensorium since yesterday evening (since 15 hours).
History of one episode of vomiting yesterday morning.
Patient was apparently asymptomatic 10 years back and then he developed giddiness and weakness on routine checkup, he was diagnosed with diabetes.
4 months back, patient had an injury to left foot with small ulcer initially and then it progressed leading to amputation of three times of left foot.
Now, yesterday patient went to his brother's house for party and had a meal of mutton curry along with 6 units of whiskey and he skipped a dose of OHA.
Since then the patient had abnormal behaviour with vomiting 1 episode - food particles as contents, non-projectile, non-bilious
No H/O Fever.
PAST HISTORY:
K/C/O DM since 10 years on T.GLIMI-M BD
He takes alcohol occasionally since 15-20 years - occasionally consumes 3-6 units of whiskey
Amputation of last 3 toes of left foot
PERSONAL HISTORY:
Diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movements- regular
Occasional alcohol intake +
No known allergies
FAMILY HISTORY: Not significant
GENERAL EXAMINATION:
GCS : E4V3M6
Pallor +
No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema
Mild dehydration +
No neck stiffness
Kernig and Brudzinski sign negative
Vitals at admission:
Temp.- Afebrile
PR- 91 bpm
RR- 24 cpm
BP- 220/110 mmHg
SpO2- 97% at RA
GRBS- 524 mg/dL
SYSTEMIC EXAMINATION:
CVS: S1S2 heard, no murmurs
RS: BAE+ NVBS+
P/A: Soft, Non-tender
CNS:
Patient is drowsy but arousable
Incoherent speech
Motor and sensory systems - couldnot be examined
Reflexes - could not be elicited
Diagnosis:
Uncontrolled sugars with altered sensorium secondary to ?DKA
Treatment given:
1. IVF - NS @ 125 ml/hr continuous IV
2. Inj. HAI 6U IV STAT
3. Inj. Thiamine 2 amp in 100 ml NS IV STAT followed by Inj. Thiamine 1 amp in 100 ml NS IV/OD
4. Inj. Zofer 4 mg IV SOS
5. Inj. Lorazepam 1 ml in 4 ml NS @ IV STAT
6. Inj. Monocef 1 gm IV BD
7. Foley's catheterisation
8. Tab. Nicardia 10 mg PO STAT
9. Vitals monitoring 4th hourly
10. GRBS monitoring every hour
Psychiatry opinion was taken i/v/o alcohol withdrawal (? intoxication) and patient was diagnosed as delirium due to ? DKA as well as alcohol withdrawal and was advised:
1. Inj. Haloperidol 1/2 ampoule(0.5 ml) 2.5 mg IM STAT
2. Inj. Lorazepam 2 mg (1/2 ampoule) 1 ml IM SOS (if patient is anxious/irritable) after informing
3. Dim lighting
4. Orientation cues
5. Adequate hydration
6. Correct the underlying cause
S.O.A.P notes
5/2/22
S-
C/O DROWSINESS AND UNRESPONSIVENESS
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema
Temp:Afebrile
PR:90bpm
BP:110/70 mm of hg
RR:26cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:Soft,non tenders
A-
UNCONTROLLED SUGARS WITH ALTERED SENSORIUM SECONDARY TO DKA.
P-
1.Ivf Ns@125ml/hr
2.Inj PAN 40 MG/IV/OD
3.INJ SODIUM BICARBONATE 50 MCG/IV/STAT
F/B INJ SODIUM BICARBONATE 100 MCG IN 400ML/NS/IV OVER 4 HOURS
4.INJ OPTINEURON 1AMP IN 100 ML NS/IV/OD
5.INJ PIPTAZ 4.5 GM/IV /STAT
F/B INJ PIPTAZ 2.25 GM /IV/TID
6.FOLEYS AND RYLES TUBE PLACEMENT
7.VITALS MONITORING
S.O.A.P
6/2/22
S-
C/O DROWSY AND RESPONDING TO ORAL COMMANDS.
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema
Temp:Afebrile
PR:66bpm
BP:110/80 mm of hg
RR:23cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:Soft,non tender
A-
UNCONTROLLED SUGARS WITH ALTERED SENSORIUM SECONDARY TO DKA.
P-
1.IVF Ns@100ml/hr
2.INJ THIAMINE 1amp in 100 ml NS/IV/OD
3.INJ ZOFER 4MG/IV/SOS
4.INJ MONOCEF 1GM/IV/BD
5.INJ LORAZEPAM 1/2 amp IV/SOS
6.INJ HAI S/C ACC TO GRBS
7.TAB QUETIAPINE 25 MG OD
8.OINT THROMBOPHOBE L/A
9.OINT T-BACT L/A
S.O.A.P notes
7/2/22
S-
C/O AWAKE AND RESPONDING TO ORAL COMMANDS
O-
O/E:
No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema
Temp:102.3 F
PR:76bpm
BP:110/70 mm of hg
RR:20cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:Soft,non tender
A-SEPTIC ENCEPHALOPATHY SECONDARY TO RT FOOT ULCER WITH METABOLIC ACIDOSIS(COMPENSTAED).
P-
1.IVF Ns@100ml/hr
2.INJ THIAMINE 1amp in 100 ml NS/IV/OD
3.INJ ZOFER 4MG/IV/SOS
4.INJ MONOCEF 1GM/IV/BD
5.INJ LORAZEPAM 1/2 amp IV/SOS
6.INJ HAI S/C ACC TO GRBS
7.TAB QUETIAPINE 25 MG OD
8.OINT THROMBOPHOBE L/A
9.OINT T-BACT L/A
10.TAB PARACETAMOL 650 MG
