60year old female brought to casuality in unresponsive state

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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+

Investigations:

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

ABG ON 28-01-2023 (04:15:PM)

PH   4.50 

PCO2  30.4 

PO2  76.6

HCO3  24.0

St.HCO3 : 26.3 

BEB : 2.2 

BEecf : 1.2 

TCO2 : 46.0 

O2 Sat : 95.7 

O2 Count : 19.5

Serum creatinine :1.2mg/dl

PHOSPHOROUS 28-01-2023:-2.0 mg/dl 

HBsAg-RAPID: Negative

HIV : Negative

ANTI HCV : Negative 

BLOOD UREA : 28- 56 mg/dl

SERUM ELECTROLYTES —

SODIUM  ; POTASSIUM ; CHLORIDE ; CALCIUM 

143 mEq/L ;   3.0 mEq/L      ; 105 mEq/L   ;1.05 mmol/L

LFT:

Total Bilurubin :1.07 mg/dl 

DB: 0.20 mg/dl 

AST:24 IU/L

ALT: 13 IU/L 

ALP: 143 IU/L

TP:6.2 gm/dl 

ALB:3.0 gm/dl 

A/G: 0.89

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.

Diagnosis:

? SEPTIC ENCEPHALOPATHY (SECONDARY TO UROSEPSIS) WITH HYPERGLYCEMIA (RESOLVED) WITH TYPE 2 DM

Treatment :

1.IVF - 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