FINAL (CASE HISTORY)

 A 50 year male farmer ,manual labourer,brought  to casualty with h/o altered sensorium 

H/o fever since 5 days.

HISTORY OF PRESENTING ILLNESS -

Patient was apparently asymptomatic 5 days ago,then he developed fever which is high grade,No diurnal variation, associated with chills.

-No h/o cough and GE symptoms. 

-Attenders tells h/o stoppage of  OHA for 3days, h/o decreased intake of food as he has fever.

-H/o altered sensorium 

-Irrelevant talk,not recognising attenders since this morning .

-Able to move all four limbs,No h/o vomitings, head ache, seizures.

-Took him to nalgonda hospital

SHIFTED HERE FOR FURTHUR MANAGEMENT. 

PAST HISTORY - 

-H/o TB 2YRS back used ATT for 6 months.

-Diagnosed as Type -2 Diabetes mellitus on OHA 1 YR back

-No H/O HTN,CVA,CAD,COVID-19.

PERSONAL HISTORY 

-DIET - MIXED,

-APPETITE -NORMAL ,

-BOWEL MOVEMENT - REGULAR , 

-BLADDER MOVEMENTS - REGULAR,

-ADDICTIONS-H/O  SMOKING 30yrs ago(1 pack per day)- 

-ALCOHOL-REGULAR INTAKE OF 180ML  SINCE 30YRS,STOPPED SINCE 2YRS AFTER DIAGNOSIS OF TB.

-RECENTLY ALCOHOL INTAKE ON JAN 15,2022.

FAMILY HISTORY:Non-significant.

TREATMENT HISTORY: 

-on OHA SINCE 1YS.

-ON ATT FOR 6MONTHS.

ON EXAMINATION -

-PATIENT IS CONCIOUS , INCOHERENT , NON COOPERATIVE

 -NO ICTRUS 

 -NO PALLOR

-CLUBBING:present.

 -NO  CYANOSIS , NO LYMPHADENOPATHY, NO  EDEMA

VITALS - 

-TEMPERATURE - 97' F

-PULSE RATE - 126BPM

-BLOOD PRESSURE - 190/80 MM OF HG 

-RESPIRATORY RATE - 28 cpm

-SPO2 - 97 % AT ROOM AIR

-GRBS-HIGH.

SYSTEMIC EXAMINATION - 

CARDIOVASCULAR SYSTEM 

- S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : 

-BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

-DYSPNOEA PRESENT.

CNS: 

-Pt is conscious, inorientation ,non cooperative 

Motor system

-unable to move right LL against gravity.

Reflexes:

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

B/L PLANTAR EXTENSION PRESENT.

O/E NECK STIFFNESS PRESENT,APPEARS TO BE ?SPONDYLOARTHROPATHY.


INVESTIGATIONS:



























PROVISIONAL DIAGNOSIS

CASE OF ALTERED SENSORIUM SECONDARY TO DKA.

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.













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