54/M with hiccups and altered sensorium
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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 diagnosis and treatment plan.
Case :
Pt c/o hiccups since 5 days
up rolling of eyeballs and frothing since morning
Chief complaints:
54 year male came to casualty on 27-10-22 with complaints of hiccups since 5 days and up rolling of eyeballs and frothing since morning
HOPI:
Pt was apparently asymptomatic 5 days back then he had hiccups for 5 days
He had up rolling of eyeballs and frothing since morning not associated with any involuntary movements or involuntary micturition
Past history:
He had similar episodes of hiccups 6 months back
2 months back he was admitted in hospital and was found out to have hypokalemia
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 a Laceration
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:
CVS: s1 s2 heard
No murmurs
Respiratory system; normal vesicular breath sounds are heard
Abdomen: soft non tender no organomegly
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 Left
- crude touch present present
- fine touch - -
- pain Present present
- Temperature Present Present
- Vibration Couldn’t be elicited
- stereognosis- Present present
- 2 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
Investigations:
Urinary potassium:
Urine sodium:
Urine chloride:
Thyroid profile:
LFT:
Random Blood sugar :
Hemogram:
CUE:
Ultrasound abdomen:
Ultrasound chest :
MRI brain :
Provisional diagnosis:
Altered sensorium
? Hypoactive delirium secondary to dyselectrolytemia
CKD ( diabetic nephropathy)
Treatment :
On 29-10-22
1) Iv fluids NS @30ml/hr
2) inj pan 40mg iv OD
3) syp potchlor 15ml in glass of water po tid
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