120-S.Nikhil kumar blog spot case study-1

            This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patient problem through series of inputs from available global online community of experts  with an aim to solve those patients clinical problem with collective current best evidence input.

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                 I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis to develop my compentency in reading and comphrending clinical data including history ,  clinical finding , investigation and come up with diagnosis and treatment plan.... 

A 64 year old male tractor driver by occupation, was brought to casualty on 18.7.2021 at 6pm in a drowsy state.

With a cheif complaints given by the patient attenders. They inform that he developed sudden drowsiness and confusion in the afternoon on 18.7.2021 after he came from work for which he was taken to an RMP where his grbs was 20mg/dl and patient was given 5%D after which he was brought to our hospital.

No h/o fall, seizure like activity, LOC, focal signs of weakness.

Past History:-

H/o similar complaints in the past - one episode 6 months ago , ome episode an year back.

Not k/c/o DM, HTN,TB, Asthma, Epilepsy,  CAD. 

Dietary history:-

Diet- mixed

Appetite- normal

Sleep- adequate 

Bowel and bladder movements- regular

Addictions- Alcoholic since 7 years. Consumes 180ml/ day. 

On Examination:-

Patient is drowsy

Vitals- PR=96bpm, RR= 16cpm, Temp= 96F,

BP= 140/90, GRBS= 116 mg/dl.

No signs of pallor, icteurs, cyanosis, Lymphadenopathy and edema. 

CVS- S1, S2 heard, no murmurs

RS- BAE+, NVBS  heard, trachea central 

P/A - Soft, non tender,  bowel sounds heard.

CNS- Speech is normal.

Neck stiffness present. 

Kernigs and Brudzinski signs are absent.

Cranial nerves- normal

Sensory system - normal

Motor system - normal. 

Investigations:-

 

Provisional Diagnosis:- 

 Starvation/alcoholic ketoacidosis. 

Plan of management:- 

Admitted in AMC.

Investigations sent- CBP, LFT, RBS, S. Creatinine, S. Electrolytes, ECG. 

Treatment:-

1) Inj. Thiamine 1 amp in 100ml NS IV/TID

2) Inj. Optineuron  1 amp in 100ml NS IV/OD

3) Tab. Pan 40 mg OD

4) Monitor BP, PR, SPO2,  Temperature 

6) Overnight 5%dextrose 

7) GRBS monitoring 2nd hrly.