ALTERED SENSORIUM- HYPOACTIVE DELIRIUM ? SECONDARY TO DYSELECTROLYTEMIA CKD (DIABETIC NEPHROPATHY) K/C/O DM2 DENOVO HTN

Case History and Clinical Findings
 54 year male came to casualty on 27-10-22 with complaints of hiccups since 5 days and altered sensorium since morning 
HOPI: 
Pt was apparently asymptomatic 5 days back then he had continuous hiccups since 5 days Altered sensorium since morning (He had ? up rolling of eyeballs and frothing 1 episode in the morning not associated with any involuntary movements or involuntary micturition or tongue bite) No h/o fever,headache,giddiness,vomiting No other complaints 
Past history:
 He had similar episode 6 months back2 months back he was admitted in hospital with similar complaints and was found out to have dyselectrolytemia - treated symptomatically K/c/o DM since 7 years ( he had trauma 5 years back to foot which was not healing properly so he went to the hospital and was diagnosed as diabetic) Initially he took medication but his sugars were not under control Then he was switched to insulin under doctor’s advice 20U in the morning and 15 units in the night since 3 months N/k/c/o HTN, asthma , epilepsy, cad, cvd H/o trauma to head ( Rta -bike skid) 1 month back he had aLaceration Personal history : Diet : mixed Appetite: normal Bowel and bladder habits: regular Addictions: none Sleep : adequate Family history: Insignificant General examination: Pt is conscious coherent and cooperative Delayed response Moderately built and nourished Pallor , icterus, cyanosis, clubbing , lymphadenopathy, edema are absent 
Vitals: Temp; 98 BP: 140/80 PR: 82 bpm RR:20/min Systemic examination: CNS; Higher functions:Right handed Conscious Delayed response Oriented to time place and person Memory: recent- present Immediate: present Remote: present Speech: slurred Cranial nerve examination: normal Spinomotor system: Right Left BULK: U/L- Normal Normal L/L- Normal Normal TONE: U/L Normal normal L/L Normal normal Right Left POWER: U/L- hand 4/5 4/5 - elbow 4/5 4/5 - shoulder 4/5 4/5 L/L- hip 4/5 4/5 - knee 4/5 4/5- ankle 4/5 4/5 Right Left REFLEXES: Biceps - Triceps - Supinator - Knee + + Ankle - Plantar Flexion Flexion 4c) Sensory system examination: As patient is drowsy examination of sensory system is limited Right Leftcrude touch present presentfinetouch - - pain Present presentTemperature Present PresentVibration Couldn’t be elicited stereognosis- Present present2 pt discrimination- - Proprioception Couldn’t be elicited Graphesthesia Absent Absent Cerebellar system : Finger nose test : unable to do Knee heel test: unable to do Finger finger: unable to do Nystagmus: no Gait: ataxic gait
 CVS: s1 s2 heard No murmurs
 Respiratory system; normal vesicular breath sounds are heard 
Abdomen: soft non tender no organomegly COURSE IN HOSPITAL: A 54/M WAS BROUGHT TO CASUALTY ON 27-10-22 WITH C/O HICCUPS SINCE 5 DAYS AND ALTERED SENSORIUM SINCE MORNING WITH STABLE VITALS AND NECESSARY INVESTIGATIONS WERE DONE AND WITH A DIAGNOSIS OF HYPOACTIVE DELIRIUM ? SECONDARY TO DYSELECTROLYTEMIA PATIENT WAS MANAGED SYMPTOMATICALLY. PATIENT IMPROVED OVER TIME AND WAS DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION WITH FOLLOWING ADVICE 
Investigation 
HEMOGRAM: ON 27-10-22: HB:12.2GM/DL, TLC:13400/CUMM, PLT:3.76LAKHS/CUMM ON 29-10-22: HB:10.1GM/DL, TLC:10,500/CUMM, PLT:3.3LAKHS/CUMM ON 30-10-22 HB:10.8GM/DL, TLC:12,500/CUMM, PLT:2.95LAKHS/CUMM ON 31-10-22 HB:10.8GM/DL, TLC:12,600/CUMM, PLT:3.13LAKHS/CUMM ON 2-11-22 HB:10.7GM/DL, TLC:10,700/CUMM, PLT:2.79LAKHS/CUMM SERUM ELECTROLYTES: ON 27-10-22: MAGNESIUM:1.8MG/DL ON 28-10-22: SODIUM:130, POTASSIUM:2.6, CHLORIDE:92ON 29-10-22: SODIUM:133, POTASSIUM:3, CHLORIDE:95 ON URINARY ELECTROLYTES: ON 27-10-22: CHLORIDE:207MMOL/L, POTASSIUM:10.7, SODIUM:188 ON 29-10-22 CALCIUM:6.50N 31-10-22 24HRS CALCIUM:104MG/DAY USG ABDOMEN: RAISED ECHOGENECITY OF B/L KIDNEYS USG CHEST: MINIMAL RIGHT PLUERAL EFFUSION MRI BRAIN: OLD LACUNAR INFARCT IN LEFT STRIATO-CAPSULAR REGION INCIDENTALLY DETECTED - PROMINENT CISTERNA MAGNA 2D ECHO: GOOD LV SYSTOLIC FUNCTION NO MR/AR/TR DIASTOLIC DYSFUNCTION + EF:58% 
Diagnosis 
ALTERED SENSORIUM- HYPOACTIVE DELIRIUM ? SECONDARY TO DYSELECTROLYTEMIA CKD (DIABETIC NEPHROPATHY) K/C/O DM2 DENOVO HTN 
Treatment Given
 1) IV fluids NS @ UO + 30ml/hr 
2) Inj pan 40mg IV OD 
3) Inj.optineuron 1 amp in 100 ml NS IV/OD 4) Syp potchlor 15ml in 1 glass of water PO/TID
 5) Inj.kcl 3 amp (60 meq) + 1 amp MGSO4 (2gm) in 500 ml NS @ 100 ml/hr 
6) Inj.H.Mixtard Insulin SC BD 20u (8am) -- x -- 15u (8pm) before meal 
7) Tab Cinod 10 mg PO/OD
 8) Strict diabetic diet
 COURSE IN HOSPITAL:
A 54/M WAS BROUGHT TO CASUALTY ON 27-10-22 WITH C/O HICCUPS SINCE 5 DAYS AND ALTERED SENSORIUM SINCE MORNING WITH STABLE VITALS AND NECESSARY INVESTIGATIONS WERE DONE AND WITH A DIAGNOSIS OF HYPOACTIVE DELIRIUM ? SECONDARY TO DYSELECTROLYTEMIA PATIENT WAS MANAGED SYMPTOMATICALLY. PATIENT IMPROVED OVER TIME AND WAS DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION WITH FOLLOWING ADVICE
 Advice at Discharge
 1) Tab Pan 40mg PO/OD 
2) Tab Zincovit PO/OD
 3) Syp Potchlor 10ml in 1 glass of water PO/BD FOR 4 DAYS
 4) Inj.H.Mixtard Insulin SC/BD 20u (8am) -- x -- 15u (8pm) before meal
5) Tab Cinod 10 mg PO/OD 
6) Strict diabetic diet &regular exercise 
Follow Up 
REVIEW TO GM / NEPHROLOGY OPD AFTER 1 WEEK WITH HEMOGRAM,RFT REPORTS ON 10-11-22

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