General Medicine Final practical short case

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome 

50 year old male brought to casuality with the chief complaints of altered sensorium since yesterday evening (since 15 hours).

Patient was apparently asymptomatic 10 years back and then he developed giddiness and weakness on routine checkup, he was diagnosed with diabetes.

4 months back, patient had an injury to left foot with small ulcer initially and then it progressed leading to amputation of three toes of left foot.

Now, yesterday patient went to his brother's house for party and had a meal of mutton curry along with 6 units of whiskey and he skipped a dose of OHA.

Since then the patient had abnormal behaviour with vomiting 1 episode - with food particles (non-projectile, non-bilious)

No history of Fever.

PAST HISTORY:

Known case of DM since 10 years on T.GLIMI-M BD

He takes alcohol occasionally since 15-20 years - occasionally consumes 3-6 units of whiskey

Amputation of last 3 toes of left foot

PERSONAL HISTORY:

Diet- mixed

Appetite- normal

Sleep- adequate

Bowel and bladder movements- regular

Occasional alcohol intake +

No known allergies

FAMILY HISTORY: 

Not significant

GENERAL EXAMINATION:

No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, pedal edema

Mild dehydration +

No neck stiffness

Kernig and Brudzinski sign negative

Vitals at admission:

Temp.- Afebrile

PR- 91 bpm

RR- 24 cpm

BP- 220/110 mmHg

SpO2- 97% at RA

GRBS- 524 mg/dL

Systemic Examination 

CVS: S1S2 heard, no murmurs

RS: BAE+ NVBS+

P/A: Soft, Non-tender

CNS:

Patient is drowsy but arousable

Incoherent speech

Motor and sensory systems - couldnot be examined

Reflexes - could not be elicited

Provisional Diagnosis 

Uncontrolled sugars with altered sensorium secondary to ?DKA

Treatment 

1. IVF - NS @ 125 ml/hr continuous IV

2. Inj. HAI 6U IV STAT

3. Inj. Thiamine 2 amp in 100 ml NS IV STAT followed by Inj. Thiamine 1 amp in 100 ml NS IV/OD

4. Inj. Zofer 4 mg IV SOS 

5. Inj. Lorazepam 1 ml in 4 ml NS @ IV STAT

6. Inj. Monocef 1 gm IV BD

7. Foley's catheterisation

8. Tab. Nicardia 10 mg PO STAT

9. Vitals monitoring 4th hourly

10. GRBS monitoring every hour