A CASE OF 60 YEAR OLD MALE

 Name: J. Akash

28/12/2022

Roll no. 53

I've 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.

Following is the view of my case :

Cheif complaints

A 60 year old male was brought to casuality with altered sensorium since yesterday night

History of presenting illness: 

Patient was apparently asymptomatic 10 years back then he developed similar kind of symptom and was diagnosed with type 2 DM and started on OHA's later after few years (?3y) patient was shifted to Insulin (HAI twice daily)

After 4yrs Patient developed giddiness and while working patients had fall ,fracture Rt UL and Rt LL And diagnosed with HTN-( on anti hypertensive medication- Telma50 -ch12.5,METXL 40 )

2 yrs back patient developed similar episodes of altered sensorium and was having Hyperglycemia he went to pvt hospital at pvt hospital then was diagnosed to have? DKA → given Insulin and treated.

10 days back pt developed swelling of lower limb , and ulceration on right toe and Plantar aspect of foot for which he went to put practictiner and diagnosed to have diabetic foot and was treated with regular dressings and antibiotics.

From 4 days pt had nausea and vomitings (2 episodes per day) with food intake ,non blood tinged 

vomitings not associated with fever ,cold ,cough,Pain abdomen, loose stools 

Past history: 

N/K/C/O asthma, CAD, Epilepsy 

PERSONAL HISTORY 

DIET MIXED 

SLEEP ADEQUATE 

BOWEL AND BLADDER MOVEMENTS REGULAR 

ALCOHOL OCCASIONAL 

NO SIGNIFICANT FAMILY HISTORY.

GENERAL EXAMINATION : 

PT IS drowsy 

NO PALOR, ICTERUS ,CYANOSIS,CLUBBING,EDEMA, LYMPHADENOPATHY 

Vitals @ admission 

Temp 98.6 F 

Pr 86bpm

Bp 130/80mm hg 

Spo2 97%

GRBS 123mg/dl

SYSTEMIC EXAMINATION: 

CVS - S1,S2 +

RS - BAE + , NVBS

CNS - Pt is drowsy , arousable to deep pains

speech slurred 

No meningial signs 

GCS E3 V2 M5

Tone : RT LT

UL. N N

LT. N. N

REFLEXES: B. T. S. K. A. Plantar

RT. ++. ++. +. ++. + flexion 

LT. +. + . +. + + flexion

INVESTIGATION:

CHEST XRAY :

    

 USG -Abdomen

MRI - BRAIN

PROVISIONAL DIAGNOSIS: 

)Altered sensorium secondary to hypotonic hyponatremia euvolemic ? SIADH

2)with small hemorraghic contusion of frontal lobe

3)With HTN since 4 years 

4)with type2 DM 

TREATMENT: 

Given on 24/12/22

Iv fluids 3% Nacl @ 15ml/hr

RT feeds - 100 ml water 1 hrly 100 ml milk 2nd hrly

Inj.kcl 20 Meq in 100 ml NS over 2 hrs /IV / STAT

Inj Zofer 4 mg /Iv/Tid

Inj Pan 40 mg / Iv / Od

Inj. Hai sc tid acc to sliding scale

Syp. potchlor 15ml/po/Tid

ICU DAY2 25/12/22

 

AGE : 60Y GENDER :M

S: 

No fever spikes

cough with sputum

O:

Pt is drowsy but arousable 

oriented to person but not time and place 

BP - 140/80 mm Hg

PR - 83 bpm

RR 21cpm

SPO2 - 98% @ RA

GRBS - 116 mg/dl

Temp - 98.4 F

CVS - S1,S2 +,Jvp not raised

RS - BAE + , NVBS

CNS - Pt is conscious but drowsy 

No meningial signs 

GCS E3 V4 M6

Tone : RT LT

UL N. N

LL N. N

REFLEXES: B. T. S. K. A. Plantar

RT. +. + . +. +. + flexion 

LT. +. +. + + + flexion 

A: 

1)Altered sensorium secondary to hypotonic hyponatremia euvolemic ? SIADH

2)with small hemorraghic contusion of frontal lobe

3)With HTN since 4 years 

4)with type2 DM 

P: 

Iv fluids 3% Nacl @ 15ml/hr( increase or decrease

 acc to serum electrolytes

RT feeds - 100 ml water 1 hrly 100 ml milk 2nd hrly

(D1)Inj monocef 1g iv bd 

Inj Zofer 4 mg /Iv sos

Inj Pan 40 mg / Iv / Od

Inj. Hai sc tid acc to sliding scale

(W/H)tab aldactone. 25 mg po bd 

tab nicardia @10 mg po bd 

coconut water through ryles tube 50ml bd 

Syp. potchlor 15ml/po/Tid

26/12/22

UNIT 5 

DR PRASUNA, INTERN

DR SANNITH, INTERN

DR HIMAJA, PGY1

DR DEEPIKA, PGY2

DR VINAY, PGY3

DR ABHINAYA, SR

ICU DAY 3

AGE : 60Y GENDER :M

S: 

No fever spikes

O:

Pt is conscious 

oriented to time and place and person 

BP - 130/80 mm Hg

PR - 83 bpm

RR 17cpm

SPO2 - 98% @ RA

GRBS @8am 161

yesterday 

8pm 129 

10pm 145 

2 am 117 

8am 161

at 2pm 143 mg

Temp - 98.4 F

CVS - S1,S2 +,Jvp not raised

RS - BAE + , NVBS

p/a soft nontender

CNS - Pt is conscious

No meningial signs 

GCS E4 V5 M6

Tone : RT LT

UL N. N

LL N. N

REFLEXES: B. T. S. K. A. Plantar

RT. +. + . +. +. - flexion 

LT. +. +. + + -. flexion 

power 

UL. 5/5. 5/5

LL. 5/5. 5/5

A: 

1)Altered sensorium secondary to hypotonic hyponatremia euvolemic ? SIADH

2)with small hemorraghic contusion of frontal lobe with AKI

3)With HTN since 4 years 

4)with type2 DM since 18yrs 

P: 

Iv fluids 3% Ns @ 50ml/hr 

RT feeds - 100 ml water 1 hrly 100 ml milk 2nd hrly

(D2)Inj monocef 1g iv bd 

Inj Zofer 4 mg /Iv sos

Inj Pan 40 mg / Iv / Od

Inj. Hai sc tid acc to sliding scale

tab nicardia @10 mg po bd 

coconut water through ryles tube 50ml bd 

Syp. potchlor 15ml/po/Tid

tab TOLVAPTAN 15MG po od

27/12/22

UNIT 5 

DR AKASH, INTERN

DR HYNDAVI, INTERN

DR HIMAJA, PGY1

DR DEEPIKA, PGY2

DR VINAY, PGY3

DR ABHINAYA, SR

ICU DAY 4

AGE : 60Y GENDER :M

S: 

No fever spikes

O:

Pt is conscious , coherent,co operative 

oriented to time and place and person 

GCS- E4 V5 M6

BP - 160/90 mm Hg

PR - 92 bpm

RR 18cpm

SPO2 - 99%

GRBS @8am 199

Temp - 98.4 F

CVS - S1,S2 +,Jvp not raised

RS - BAE + , NVBS

P/A soft nontender

CNS - HMF intact

Tone : RT LT

UL N. N

LL N. N

REFLEXES: B. T. S. K. A. Plantar

RT. ++ + . +. +. + flexion 

LT. ++ +. + + + flexion 

power 

UL. 5/5. 5/5

LL. 5/5. 5/5

A: 

1)Altered sensorium secondary to hypotonic hyponatremia euvolemic ? SIADH

2)with small hemorraghic contusion of frontal lobe with AKI

3)With HTN since 4 years 

4)with type2 DM since 18yrs 

P: 

Iv fluids Ns @ 50ml/hr 

RT feeds - 100 ml water 1 hrly 100 ml milk 2nd hrly

(D3)Inj monocef 1g iv bd 

Inj Zofer 4 mg /Iv sos

Inj. Hai sc tid acc to sliding scale

tab nicardia @10 mg po bd 

Syp. POTCHLOR 15ml/RT/Tid

tab TOLVAPTAN 15MG po od

28/12/22

UNIT 5 

DR HIMAJA, PGY1

DR DEEPIKA, PGY2

DR VINAY, PGY3

DR ABHINAYA, SR

DR AKASH, INTERN

DR HYNDAVI, INTERN

AMC, DAY 5

AGE : 60Y GENDER :M

S: 

No fever spikes

O:

Pt is conscious , coherent,co operative 

oriented to  time and place and person 

GCS- E4 V5 M6

BP - 130/90 mm Hg

PR - 96 bpm

RR 16cpm

SPO2 - 98%

GRBS @8am 224

Temp - 98F

CVS - S1,S2 +,Jvp not raised

RS - BAE + , NVBS

P/A soft nontender

CNS - HMF intact

Tone :      RT       LT

UL            N.         N

LL             N.         N

REFLEXES:  B.     T.       S.      K.     A.     Plantar

RT.                 +        +  .     +    +.      +      flexion 

LT.                 +         +        +     +      +     flexion 

power 

UL.          5/5.        5/5

LL.           5/5.       5/5

A: 

1.Altered sensorium secondary to hyponatremia euvolemic ? SIADH?

2)with small hemorraghic contusion of frontal lobe with AKI(resolving)

3)With HTN since 4 years 

4)with type2 DM  since 18yrs 

P: 

Iv fluids  Ns @ 50ml/hr 

RT feeds - 100 ml water 1 hrly 100 ml milk 2nd 

(D4)Inj monocef  1g iv bd 

Inj Zofer 4 mg /Iv sos

Inj. Hai sc tid acc to sliding scale

tab nicardia @10 mg po bd 

Syp. POTCHLOR 15ml/RT/Tid

tab TOLVAPTAN 15MG po /od