60F with septic encephalopathy with DM 2

DOA - 28/1/2023
Discharge Date
Date: 3/2/23
Ward:AMC
Unit:6

Diagnosis
? SEPTIC ENCEPHALOPATHY (SECONDARY TO UROSEPSIS) WITH HYPERGLYCEMIA(RESOLVED) WITH TYPE 2 DM

Case History and Clinical Findings
PATIENT WAS BROUGHT TO CASUALITY IN UNRESPONSIVE STATE.
PATIEN WAS APPARENTLY ASYMPTOMATIC 3 YEARS BACK THEN SHE DEVELOPEDGENERALISED WEAKNESS FOR WHICH SHE VISITED LOCAL HOSPITAL AND WASDIAGNOSED WITH TYPE 2 DM. SINCE THEN PATIENT WAS ON IRREGULAR MEDICATION.TODAY MORNING PATIENT ATTENDERS NOTICED THAT PATIENT WAS IN UNRESPONSIVESTATE AND WAS UNABLE TO WAKEUP FROM SLEEP AND WAS TAKEN TO LOCAL RMP (HIGHSUGARS 600 MG/DL WAS OBSERVED) AND WAS REFERRED TO OUR HOSPITAL INUNRESPONSIVE STATE, HER GCS - E1V1M6.
NO H/O ABNORMAL MOVEMENTS, HEADACHE,VOMITING.K/C/O DM2 SINCE 3 YRS AND ON IRREGULAR MEDICATION.NOT K/C/O HTN,ASTHMA, CAD, EPILEPSY.
PERSONAL HISTORY :A
PPETITE - NORMALDIET - MIXED


BOWEL AND BLADDER - REGULARSLEEP - ADEQUATE
ADDICTIONS : OCCASIONAL TODDY-ONCE A WEEKTOBACCO(BEEDI) FROM 20 YEARS, STOPPED 3 YEARS AGOGENERAL EXAMINATION :
NO PALLOR, ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY,PEDAL EDEMAVITALS ON ADMISSION:
TEMP- 101 FPR-90 BPM
BP- 100/70MM HGRR- 20 CPMSPO2-97%ATRA
GRBS - 226 MG/DLSYSTEMICEXAMINATION:
1) PER ABDOMEN:
INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLYWITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.
PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.ASCULTATION: BOWEL SOUNDS - HEARD2)RESPIRATORY SYSTEM:
INSPECTION:SHAPE OF THE CHEST IS ELLIPTICAL,B/L SYMMETRICAL.BOTH SIDES MOVINGEQUALLY WITH RESPIRATION..NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL
IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL .VOCAL FREMITUS IS NORMAL
PERCUSSION: RESONANT B/LASCULTATION:BAE+,NVBSHEARD
CVS:
INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NOSCARS,SINUSES,ENGORGED VEINS,PULSATIONS.
PALPATION: APEX BEAT FELT IN LEFT 5TH ICS.NO THRILLS AND PARASTERNAL HEAVES.ASCULTATION: S1S2 +,NO MURMURS
CNS:
GCS - E1V1M6
B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT


NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEM-NORMAL,
MOTOR SYSTEM: TONE- NORMAL, POWER- 0/5 IN RIGHT UL AND LL , 2/5 IN LEFT UL AND LLREFLEXES : BICEPS - 1+ , TRICEPS-1+ , SUPINATOR - 1+ ,KNEE - 1+ , ANKLE - 1+

BRIEF COURSE IN HOSPITAL: PATIENT WAS BROUGHT TO THE CASUALITY INUNRESPONSIVE STATE , HER GCS BEING E1V1M6 NECESSARY INVESTIGATIONS WEREDONE AND UPON EVALUATION SHE WAS FEBRILE(102 F) &HER SUGARS WERE HIGH600MG/DL ,FOR WHICH SHE WAS TREATED ACCORDINGLY . HER C/S REPORT REVEALEDECOLI GROWTH AND WAS STARTED ON ANTIBIOTICS TO TREAT HER UROSEPSIS .PATIENTIS BEING DISCHARGED UNDER HEMODYNAMICALLY STABLE CONDITION.

Investigation
1)HEMOGRAM:
29/01/23
HB : 13.0 mg/dlPCV : 24.8%
TLC : 13500 CELLS/CUMMPLAT: 1.8 LAKH/CUMM30/01/23
HB : 11.1 mg/dlPCV : 34.5%
TLC : 13400 CELLS/CUMMPLT : 1.7 LAKH/CUMM31/01/23
HB : 10.6 mg/dlPCV: 33.1 %
TLC : 6900 CELLS/CUMMPLT : 1.7 LAKH/CUMM01/012/23
HB : 10.8 mg/dlPCV : 33.3%
TLC : 6700 CELLS/CUMMPLT : 2.1 LAKH/CUMM

USG ABDOMEN: NO SONOLOGICAL ABNORMALITY DETECTED
USG NECK: TRIRADS 3 LESION IN RIGHT LOBE OF THYROIDTRIRADS 2 LESION IN LEFT LOBE OF THYROID
BLOOD C/S : NO GROWTH SEEN
URINE C/S : E.COLI ISOLATED.
2D ECHO : NO RWMA , CONCENTRIC LVH+TRIVIAL TR+/MR+/AR+
NO AS, MSEF=62%
GOOD LV SYSTOLIC FUNCTION, DIASTOLIC DYSFUNCTION +, NO PE,PAH.

Treatment Given(Enter only Generic Name)
VF - NS@ 75ML/HR
INJ.PIPTAZ 4.5 GM IV/TID
3.T NITROFURONTOIN 100 MG PO/BD4.INJ PAN 40 MG IV OD
INJ KCL 20 MEQ IN 100 ML NS
INJ MAGNESIUM 1 AMP IN 100 ML NS
7.T DOLO 650 MG PO/TID
SYP POTCHLOR 10 ML PO/TID
INJ HAI S/C ACCORDING TO GRBS

Advice at Discharge
1.T NITROFURANTOIN 100 MG PO/BD X 3DAYS
2.T PAN 40 MG PO/OD X 3 DAYS
3.SYP POTCHLOR 10 ML PO/TID X 3 DAYS
4.T GLIMI M1 PO/BD X TO BE CONTINUED

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