Case of a 55 year old male with fever and altered sensorium

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   I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a  diagnosis and treatment plan.

CASE PRESENTATION :

This is a case of a 55 year old male, farmer by occupation who presented with:

CHIEF COMPLAINTS:

Fever since 4 days

Altered sensorium since 1 day

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 4 days back, then he developed high grade fever with chills, with no diurnal variation. 

H/o altered sensorium since 1 day.

Patient had apparently stopped taking OHA for 3 days. 

He was talking irrelevantly and was unable to recognize his relatives since 6/2/22 morning. 

So he was taken to Nalgonda hospital where his TLC:13,000, creatinine: 2.9 . He was shifted to the present hospital for further management

He was able to move all his four limbs.

No H/O vomitings, headache, seizures.

PAST HISTORY :

Patient had H/O TB 2 years back for which he used ATT for 6 months.

He was a K/C/O  Type 2 Diabetes mellitus since 1 year and from then he has been on OHA. 

No H/O HTN, asthma, CHD. 

PERSONAL HISTORY :

Diet:  Mixed

Appetite: Normal

Sleep: Adequate

Bowel and bladder habits: Regular

Addictions:  H/O smoking since 30yrs (1 pack per day)

 Consumption of alcohol about 180ml/day since 30 years, decreased intake since 2 years after diagnosis of TB. 

FAMILY HISTORY:    Insignificant

GENERAL EXAMINATION:

Patient is conscious, incoherent, non-cooperative

 No pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema

VITALS :

Temperature: 97°F

Pulse rate :126 bpm

Blood Pressure : 190/80 mmHg

Respiratory rate : 28cpm

SPO2 - 97 % at RA

GRBS- 436 mg/dl

SYSTEMIC EXAMINATION:

CVS : S1  S2 heard , no murmurs

RS: Bilateral Air entry present, NVBS

Dyspnoea present

P/A :  soft,non tender

CNS: 

Patient is conscious, not oriented ,non cooperative 

HMF: couldn't be elicited.

Motor system: unable to move right LL against gravity.

Tone -     Rt            Lt

U/L           N             N

L/L         ?HYPO       N            

Reflexes:

Biceps, triceps, supinator, knee, ankle: can't be elicited.

 O/E  Neck stiffness present , appears to be? Spondyloarthropathy

LAB INVESTIGATIONS:

On 6/2/22

On 7/2/ 22

On 8/2/22:

ECG:

CXR:

PROVISIONAL DIAGNOSIS:

Hyperosmolar Nonketotic state ē Diabetic Nephropathy 

TREATMENT :

1.IVF 2 UNITS NS IV_BOLUS/STAT.

AND THEN IVF NS@100ML/HR

2.INJ.HAI 6U/IV/STAT

3.INJ.HUMAN ACTRAPID 1ML(40U) 

4.INJ.THIAMINE 1AMP IN 100ML NS/IV/OD

5.INJ.OPTINEURON 1 AMP IN 100ML NS/IV/OD

6.GRBS MONITORING-EVERY HOURLY.

7.INJ.MONOCEF 2GM/IV/BD.