A 55 year old gentleman was brought to casualty in an unconscious state by his attenders who gave the history that an hour ago the patient had developed stiffness of both upper and lower limbs with repetitive blinking of eyes for 2 minutes followed by involuntary micturition. There was no history of uprolling of eye balls, tongue bite nor frothing at mouth.
The patient didn't regain consciousness thereafter.
Similar episode occured in hospital which lasted for 2 minutes.
Another episode occured after 15 minutes following the second episode again lasting for 2 min .
The patient didn't regain consciousness inbetween the episodes.
After 1 hour the patient became irritable.
The patient also has history of shortness of breath since one year,for which he has been on medication . since 4 days Sob
has progressed from grade III to grade IV since the morning.
There no history suggestive of orthopnea, paroxysmal nocturnal dyspnea.
The patient is a chronic alcoholic who consumes 180 ml of whiskey per day.
He was also a chronic smoker who had been smoking about 40 beedis per day for the past 20-30 yrs but has stopped smoking 3 yrs ago
He also had SOB (grade IV) 3 years ago for which he took medication for 1 month and was advised by his doctor to quit smoking and drinking. He has stopped smoking but continued drinking.
GENERAL EXAMINATION
E1V1M1——>E1V2M4
Vitals
BP 100/80
PR : 145
RR : 23
SPO2: 98
RBS : HIGH
No pallor , icterus, cyanosis, clubbing , generalized lymphedema or pedal edema present
SYSTEMIC EXAMINATION
CNS
Rt Lf
Tone UL. Hypo. Hypo
LL. Hypo. Hypo
Power UL. - -
LL. - -
Reflexes B. 1+. 1+
T. 1+. 1+
S. 1+. 1+
K. 1+. 1+
A. - -
P. Withdrawal. Mute
No signs of meningeal irritation present
CVS
S1, S2 heard
No murmurs or thills
Respiratory system
Barrel shaped chest
Symmetrical expansion
Trachea central in position
BAE +, NVBS
PER ABDOMEN
Soft , non tender
Hernial orifices intact
No organomegaly detected
INVESTIGATIONS
pH - 7.1
PCo2 - 39.2
Hco3 - 11.8
PO2 - 144
So2 - 95.3
Urinary ketone bodies - negative
HBA1C - 8.5
RBS - 731
UREA- 83
Creatinine - 1.4
Na+ 130
K+ 4.2
Cl- 95
Anion gap - 28
Serum osmolality - 190.6
Calculated serum osm. - 314.46
Osm. gap - 123.86
1) Chest X-RAY
2) ECG
DAY 1
SUBJECTIVE :
SOB since morning
OBJECTIVE :
Afebrile
BP 100/60
PR 86
RR 15
sPO2 98%
RS BAE +, Inspiratory wheeze
P/A Soft Tender
CNS
Tone
Rt. Lt
UL. N. N
LL. N. N
Power
UL. 5/5. 5/5
LL. 5/5. 5/5
Reflexes
B / T /S. B/L - 1+
K (B/L) - +1
Ankle (B/L) - withdrawal
Plantar - Flexor (B/L)
ASSESSMENT - ?DKA
? Hyperglycemic Seizures
PLAN -
1. Inj METROGYL 100 ML I V. TID
2. Inj MONOCEF 1GM I.V. BD
3. INJ ACTRAPID INFUCISON TILL ACIDOSIS RESOLVES (30 ML NS + 1 ML HAI)
4. INJ. LASIX 40 MG IV. BD 8 am and 4 pm (only if SBP is >110 mm of Hg)
5. IVF 5% DEXTROSE @ 50ML /HR
(ONLY IF GRBS IS <200MG/DL TILL ACIDOSIS RESOLVES)
6..IVF NS @ 75 ML PER HR
7. O2 INHALATION TO MAINTAIN SPO2 >92%
8. STRICT I/O CHARTING
9. GRBS 1 HRLY
Psychiatric Referral done:
Day 2
SUBJECTIVE :
SOB since morning
OBJECTIVE :
Afebrile
BP 100/60
PR 86
RR 15
sPO2 98%
RS BAE +, Inspiratory wheeze
P/A Soft Tender
CNS
Tone
Rt. Lt
UL. N. N
LL. N. N
Power
UL. 5/5. 5/5
LL. 5/5. 5/5
Reflexes
B / T /S. B/L - 1+
K (B/L) - +1
Ankle (B/L) - withdrawal
Plantar - Flexor (B/L)
ASSESSMENT - ?DKA
? Hyperglycemic Seizures
PLAN -
1. Inj METROGYL 100 ML I V. TID
2. Inj MONOCEF 1GM I.V. BD
3. INJ ACTRAPID INFUCISON TILL ACIDOSIS RESOLVES (30 ML NS + 1 ML HAI)
4. INJ. LASIX 40 MG IV. BD 8 am and 4 pm (only if SBP is >110 mm of Hg)
5. IVF 5% DEXTROSE @ 50ML /HR
(ONLY IF GRBS IS <200MG/DL TILL ACIDOSIS RESOLVES)
6..IVF NS @ 75 ML PER HR
7. O2 INHALATION TO MAINTAIN SPO2 >92%
8. STRICT I/O CHARTING
9. GRBS 1 HRLY
Day 3
SUBJECTIVE :
SOB And Cough
OBJECTIVE :
Afebrile
BP 100/60
PR 86
RR 15
sPO2 98%
RS BAE +, Inspiratory wheeze
P/A Soft Tender
CNS
Tone
Rt. Lt
UL. N. N
LL. N. N
Power
UL. 5/5. 5/5
LL. 5/5. 5/5
Reflexes
B / T /S. B/L - 1+
K (B/L) - +1
Ankle (B/L) - withdrawal
Plantar - Flexor (B/L)
ASSESSMENT -
?DKA
? Hyperglycemic Seizures
With Rt. UL cellulitis
With Rt heart failure
PLAN -
1. Inj METROGYL 100 ML I V. TID
2. Inj MONOCEF 1GM I.V. BD
3. INJ. HAI S/C According to sliding scale
4. INJ. LASIX 40 MG IV. BD 8 am and 4 pm (only if SBP is >110 mm of Hg)
5..IVF NS @ 75 ML PER HR
6. O2 INHALATION TO MAINTAIN SPO2 >92%
7. STRICT I/O CHARTING
8. GRBS 1 HRLY
Day 4
SUBJECTIVE :
SOB And Cough
OBJECTIVE :
Afebrile
BP 100/60
PR 86
RR 15
sPO2 98%
RS BAE +, Inspiratory wheeze
P/A Soft Tender
CNS
Tone
Rt. Lt
UL. N. N
LL. N. N
Power
UL. 5/5. 5/5
LL. 5/5. 5/5
Reflexes
B / T /S. B/L - 1+
K (B/L) - +1
Ankle (B/L) - withdrawal
Plantar - Flexor (B/L)
ASSESSMENT -
?DKA
? Hyperglycemic Seizures
With Rt. UL cellulitis
With Rt heart failure
PLAN -
1. Inj METROGYL 100 ML I V. TID
2. Inj MONOCEF 1GM I.V. BD
3. INJ. HAI S/C According to sliding scale
4. INJ. LASIX 40 MG IV. BD 8 am and 4 pm (only if SBP is >110 mm of Hg)
5..IVF NS @ 75 ML PER HR
6. O2 INHALATION TO MAINTAIN SPO2 >92%
7. STRICT I/O CHARTING
8. GRBS 1 HRLY
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