64 Y OLD MALE WITH DROWSINESS

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This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment plan.

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

Patient attenders 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.

History of 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. 

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. 

Provisional Diagnosis:- 

? Starvation/alcoholic ketoacidosis. 

Investigations:-

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.