Case 31 40 Male with altered sensorium

DOA 15/8/24

EXPIRED ON 17/8/24

Diagnosis

ALTERED SENSORIUM SECONDARY TO HYPOGLYCEMIA?HYPOXIC ENCEPHALOPATHY

GTCS SECONDARY TO ?HYPOGLYCEMIA

WITH ASPIRATION PNEUMONIA

WITH LEFT DAIBETIC FOOT

WITH K/C/O DIABETES MELLITUS TYPE 2 SINCE 10 YEARS

POST INTUBATION ON MECHANICAL VENTILATION DAY 2

WITH GRADE 2 BED SORE

Case History and Clinical Findings

PATIENT WAS BRUGHT TO CASUALTY IN INTUBATED STATE

HOPI:PATIENT WAS APPARANTLY NORMAL UNTIL 2 AM TODAY THEN WIFE NOTICED

SNORING WITHOUT ANY RESPONSE,SWEATING PRESENT

HE WAS THE TAKEN TO A LOCAL HOSPITAL AND FOUND GRBS AT 25 MG/DL AND 25D

INFUSION WAS GIVEN

PATIENT DID NOT GAIN CONSCIOUSNESS EVEN AFTER 25 D AND HE WAS REFFERED TO

HIGHER CENTRE

PATIENT HAD 1 EPISODE OF INVOLUNTARY MOVEMENTS OF UPPER AND LOWER LIMBS

WITH GENERALISED CLONIC MOVEMENTS FOR A PERIOD OF 15 MINUTES

HE WAS THEN TAKEN TO ANOTHER HOSPITAL WHERE HE WAS INTUBATED AND THEN

PATIENT WAS BROUGHT TO OUR HOSPITAL

NO C/O VOMITINGS

URINARY INCONTINENCE PRESENT

PAST HISTORY:H/O SIMILAR COMPLAINTS IN TE PAST 2 MONTHS 3 EPISODES REGAINED

CONSCIOUSNESS AFTER 25D INFUSION

K/C/O DM TYPE2 SINCE 10 YEARS ON INJ.INSULIN H.MIXTARD

NOT A K/.C/O HTN,CVS,CAD,THYROID,ASTHMA,TB

PERSONAL HISTORY:

MIXED DIET

APPETITE-NORMAL

BOWEL MOVEMENTS REGUALR

MICTURITION-URINARY INCONTINENCE PRESENT

NO ALLERGIES

ADDICTIONS-REGULAR ALCOHOL CONSUMPTION STOPPED TWO MOTNHS AGO

FAMILY HISTORY:NOT SIGNIFICANT

GENERAL EXAMINATION:

PATIENT IS INTUBATED

VITALS:

TEMP-99.9

BP-90/60

PR-96

RR-22

SPO2-93%ON MV

GRBS-75MG/DL

GCS-E1VTM1

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDAL EDEMA

SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD,NO MURMURS

RS:BAE PRSENT RIGHT>LEFT,ET TUBE POSITION READJUSTED

B/L CREPTS PRESENT IN IAA,MA,ISA

MECHANICAL VENTILATION-MODE-ACMV -VC

TIDAL VOLUME-400ML

PEEP-5

FIO2-100

PA:SOFT,NONTENDER

CNS:GCS-E1V1M1

REFERRED TO SURGERY I/V/O DIBETIC FOOT:

DAISGNOSIS:LEFT FOOT DIABETIC FOOT ULCER WITH ALTERED SENSORIUM SECONDARY

TO HYPOGLYCEMIA

ADVICED OINT .T-BACT FOR L/A

REGULAR DRESSING

CONTINUE SAME TREATMENT

INVESTIGATION-SWAB FOR C/S

B/L LOWER LIMB AV DOPPLER

REFERRED TO OPTHALMOLOGY I/V/O DIABETIC RETINOPATHY:

IMPRESSION:NORMAL FUNDUS STUDY

REFERRED TO DERMATOLOGY I//V/O MULTIPLE PAPULAR SKIN LESIONS:

DIAGNOSIS:ACNEFORM ERUPTION+POST INFLAMMATORY HYPER PIGMENTATION

ADVICED BENZAL -AC GEL 2.5% /A OD AT NIGHT FOR 2 WEEKS

PLBS,FBS

Investigation

HEMOGRAM: 15.08.24

HB: 10.9

TC: 12,300

N/L/E/M//B: 88/8/1/3/0

PLT: 2.83

RBC: 4.04

SMEAR: NORMOCYTIC NORMOCHROMIC

HEMOGRAM: 16.08.24

HB: 8.3

TC: 12,200

N/L/E/M//B: 72/23/01/04/00

RBC:3.08

PLT: 2.34

SMEAR: NORMOCYTIC NORMOCHROMIC WITH LEUKOCYTOSIS

RFT ON 15.8.24

UREA: 16

CREAT: 1.3

URIC ACID: 4.4

CA/P/NA/K/CL: 8.4/3.2/141/4.0/102

RFT ON 17.8.24

UREA: 20

CREAT: 1.2

URIC ACID: 3.8

CA/P/NA/K/CL: 8.4/2.4/141/3.7/105

LFT ON 15.8.24

TOTAL BILIRUBIN:0.59

DIRECT BILIRUBIN :0.15

AST:22

ALT:17

ALP:227

TOTAL PROTEIN:4.4

ALBUMIN:1.9

A/G RATIO:0.77

CUE 15.08.24

COLOUR: PALE YELLOW

APP.: CLEAR

SP. GRAVITY : 1.010

ALBUMIN : ++

SUGAR : NIL

PUS CELLS : 3-4

EPI. CELLS : 2-4

RBS - 156MG/DL

FBS 96 MG/DL

PLBS 196 MG/DL

HbA1C - 6.9%

LIPID PROFILE ON 16.08.24

T.CHOLESTROL:75

TGA:96

HDL:13

LDL;44.8

VLDL:11.2

2D ECHO DONE 16/08/24

NO RWMA

TRIVIAL TR+ NO PAH RSVP=32MMHG

TRIVIAL AR+ ; NO MR

NO AS/MS ;IAS INTACT

EF =67% GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION

NO PE /LV CLOT

IVC SIZE 0.7CMS COLLAPSING

USG ABDOMEN ON 15.08.24

LIVER NORMAL S/E NO F/L

PV/CBD-NORMAL

GALL BLADDER -DISTENDED

PANCREAS- HEAD VISUALISED NORMAL S/E

SPLEEN - 8CM NORMAL S/E

RIGHT KIDNEY - 9.4 X 3.5 CM NORMAL SIZE / RAISED ECHOGENICITY

LEFT KIDNEY - 9.5X3.4 CM NORMAL S/E

AORTA IVC - NORMAL , NO ASCITIS

NO LYMPHADENOPATHY

URINARY BLADDER - EMPTY

FOLEY'S IN SITU

IMPRESSION: RAISED ECHOGENICITY OF RIGHT KIDNEY

Treatment Given(Enter only Generic Name)

1)RT FEEDS 100 ML MILK WITH PROTEIN POWDER 4TH HOURLY

50ML WATER 2ND HOURLY

2)INJ.MIDAZOLAM INFUSION (25ML+25ML NS) 0.5MG/ML @10ML/HOUR

3)INJ.FENTANYL INFUSION (4ML +46ML NS) 4MCG/ML @ 7ML/HOUR

4)INJ.NORADRENALINE INFUSION (4ML+46ML NS)0.16 MG/ML @2.5 ML/HOUR

INCREASE/DECREASE TO MAINTAIN MAP >65MM HG

5)IV FLUIDS NS @ 50ML /HOUR

6)INJ.MEROPENEM 1GM IV/BD (DAY 3)

7)INJ.CLINDAMYCIN 600 MG IV/BD (DAY 3)

8)INJ.LEVIPIL 500MG IN 100ML NS IV/BD

9)INJ.THIAMINE 100MG IN 100ML NS IV/BD

10)INJ.NEOMOL 1GM IV/SOS (IF TEMP.>101F)

11)INJ.GLYCOPYRROLATE 2CC IV/SOS

12)NEB WITH DUOLIN,BUDECORT AND MUCOMIST 12TH HOURLY

13)T.BACT OINT FOR LA

14)MONITOR BP,PR,RR,SPO2 HOURLY

15)GRBS MONITORING 4TH HOURLY

16)POSITION CHANGE 2ND HOURLY

17)ET/ORAL SUCTIONING HOURLY

18)REGULAR WOUND DRESSING

Follow Up

DEATH SUMMARY:

A 49 YEAR OLD MALE WAS BROUGHT TO CASUALTY IN AN INTUBATED STATE WITH

VENTILATOR SETTINGS FiO2 : 100% , RR: 14CPM , VT: 450ML,PEEP :5CM H2O ON 15/08/24 AT

AROUND 8 AM. PATIENT INITIALLY HAD AN EPISODE OF HYPOGLYCEMIA AT AROUND 2AM

ON 15/8/24 AND WAS TAKEN TO NEARBY HOSPITAL AND HIS GRBS WAS 25 MG/DL AND WAS

GIVEN DEXTROSE BUT PATIENT DID NOT GAIN CONSCIOUSNESS AND HE WAS THEN

REFERRED TO HIGHER CENTRE. HE WAS THEN TAKEN TO ANOTHER HOSPITAL AND

PATIENT ON THE WAY HAD AN EPISODE OF GTCS FOR ABOUT 15MINUTES AND ON

REACHING THE HOSPITAL HE WAS INTUBATED I/V/O POOR GCS . PATIENT WAS THEN

BROUGHT TO OUR HOSPITAL FOR FURTHER MANAGEMENT. AS THE PATIENT WAS

CONTINUOUSLY SEDATION WAS INITIATED (INJ.MIDAZOLAM AND INJ.FENTANYL) AND ALSO

PATIENT DEVELOPED HYPOTENSION IONOTROPIC SUPPORT WAS STARTED

(INJ.NORADRENALINE) AND PUT ON ANTIBIOTICS. PATIENT IS A K/C/O DM SINCE 10 YEARS

AND HE WAS HAVING AN ULCER OVER LEFT FOOT FOR WHICH SURGERY OPINION WAS

TAKEN AND DRESSINGS DONE.

ON DAY 2 PATIENT WAS CONTINUED ON SEDATION AND IONOTROPIC SUPPORT.

ON DAY 3 PATIENT WAS CONTINUED ON IONOTROPIC SUPPORT AND SEDATION WAS

SLOWLY TAPERED.

AT AROUND 9:30 AM ON 17/8/24 PATIENT SUDDENLY DEVELOPED BRADYCARDIA WITH FALL

IN SATURATIONS AND CPR WAS INITIATED AT 9:40 AM IN VIEW OF ABSENT ABSENT

CENTRAL AND PERIPHERAL PULSES AND INJ.ATROPINE AND ADRENALINE WERE GIVEN

AND CPR WAS CONTINUED FOR 30MINS. INSPITE OF ALL THESE RESUSCITATIVE EFFORTS

PATIENT COULD NOT BE REVIVED AND DECLARED DEAD ON 17/08/24 AT 10:10 AM

IMMEDIATE CAUSE OF DEATH: HYPOXIC ENCEPHALOPATHY

ANTECEDENT CAUSE : ALTERED SENSORIUM SECONDARY TO HYPOGLYCEMIA , HYPOXIA

WITH GTCS SECONDARY TO HYPOGLYCEMIA

WITH ASPIRATION PNEUMONIA

WITH LEFT DIABETIC FOOT WITH K/C/O DM SINCE 10 YEARS

Death Date

17/08/24 AT 10:10AM