80 year old male patient presented in unresponsive state

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80 year old male 

Chief complaints: 

Presented to casualty in unresponsive state since 2hrs on 14/09/22

He was apparently asymptomatic one day back then he presented to the casualty in an unresponsive state since 4am associated with profuse sweating.

His day starts at 5am , he Wakes up and sits for a while then he walks his around with goat that he has been rearing. He does his breakfast at 8am, lunch at 3pm sleeps for a while and then rears the goat for a while then , dinner at 7pm . He Sleeps at around 8-9 pm . He wakes in the middle of the night sometimes if he were hungry and eats rice with milk and goes back to sleep. 

On the night of incident he had his dinner at 7pm and went to bed around 9. He woke up at 12 and had rice with milk at 12am and went back to sleep. Later at 5 am he woke up hungry and had rice with milk . In a few minutes he fell on to the bed and was asking for help . He was taken to govt. hospital nearby where he was given treated and then referred to our hospital where he presented in an unresponsive state.

Past history : 

H/o fever 1 year back which lasted for 1 week it was associated with chills and rigors, cough . He also complained of breathlessness. - he went to local hospital and was given medication for 1 month. The fever subsided and he was doing fine

No similar complaints in the past . Non alcoholic, non smoker. No h/o drug usage

No c/o SOB , Orthopnea, PND No chest pain / palpitations/syncopal attacks. 

H/o fever 20 days back 

N/k/c/o HTN /DM/CAV / TB/ EPILEPSY

Personal history: 

Diet : mixed 

Appetite: normal

Sleep : regular

Bowel and bladder: regular

Addictions: he used to consume alcohol occasionally 90ml whisky during festivals. Stopped consuming alcohol since 2 years 

No h/o smoking

On general examination

 Patient was concious, unresponsive

No pallor, Icterus, clubbing, cyanosis, edema , lymphadenopathy

Vitals : 

Temp. 98.3°F 

BP - 160/90mmHg

PR- 86bpm

CVS- S1 S2 + , loud s2

RS- BAE +

P/A- soft. NT

GRBS -64mg/dl 

Provisional diagnosis: recurrent Hypoglycemia resolved , ? Sepsis

Type II respiratory failure. 2° to ? CAP with old ? PTB . 

Investigations 

14/09/22

                  Hemogram 

ABG at 9:48 am

ABG at 4:40 pm

                                    RFT

CHEST X RAY 

15/09/22

                          Hemogram

ESR - 20 mm/ 1st hr.

Serum creatinine - 0.8 mg/dl

Serum electrolytes - 

Na- 136mEq/L

K- 3.3 mEq/L

Cl - 0.86 mmol/L

      

                            ABG 

      

                    CUE

15-09-22

Treatment 

1) INJ. 25 % DEXTROSE @ 50 ml/ hr (target range

: 120-180mg/dl)

2) NEBULIZATION T DUOLIN 6th hrly, BUDECORT 8th hrly

3) BP, PR, RR, CHARTING 4th hrly. 

4) INJ. LASIX 20 mg stat. 

16/09/22

S: pt. Is sedated and paralysed 

O :

Pt is , on mechanical ventilator

Temp- 98.0 °F

PR:88bpm

BP:100/60

CVS: S1 S2 +, LOUD S2

RS: BAE+

SpO2 100% , 

TFiO2 - 40

RR- 25

PEEP- 8

I:E- 1:3

Peak - 20

TV -300ml

GRBS- 187 mg/dl ,

P/A: soft , non tender 

A: recurrent hypoglycemia 2° ? Insulin auto immune syndrome, ? Sepsis ? PTB

Type 2 respiratory failure 2° to CAP 

P:

1)INJ. 25% DEXTROSE @15ml/hr to maintain RBS 120-180mg/dl

2) IVF- NS 30 ml/hr

3) INJ. LASIX 20mgIV/BD 

4) RT FEEDS @75ml/2nd hrly

5) INJ. MIDAZOLAM 10ml +40ml NS @ 5ml/hr 

6) INJ ATRACURIUM 5ml+ 45ml NS @ 5ml/hr

7) BP/PR/RR/SPO2/GRBS CHARTING

8) AIR BED. 

17/09/22

Hemogram

ABG

18/09/22

 RFT 

HEMOGRAM 

19/09/22

RFT

HEMOGRAM 

S:SOB improved 

O :

Pt is concious , coherent and cooperative 

Temp- 99.8°F

PR:91bpm

BP:100/60mmHg

CVS: S1 S2 +

RS: BAE+, NVBS

CNS: NAD

SpO2: 98%

GRBS- 112 mg/dl ,

P/A: soft , non tender 

A: recurrent hypoglycemia 2° ? Insulin auto immune syndrome, ? Sepsis ? 

Type 2 respiratory failure 2° to ? active PTB ?CAP 

P:

1) IVF- NS @ 30 ml/hr

2) INJ. LASIX 20mgIV/BD 

3) TAB.ISONIAZID 75mg

     TAB.RIFAMPICIN 150mg

     TAB. PYRAZINAMIDE 400mg

     TAB. ETHAMBUTOL 275mg

     (3 TAB PO/OD)

4)BP/PR/RR/SPO2/GRBS CHARTING

5) AIR BED. 

22/09/22

S:SOB improved 

O :

Pt is concious , coherent and cooperative 

Temp- 98.0°F

PR:80bpm

BP:110/80mmHg

CVS: S1 S2 +

RS: BAE+

CNS: NAD

SpO2: 92% with 2L of O2 and over night CPAP

GRBS- 80 mg/dl ,

P/A: soft , non tender 

A: 

Type 2 respiratory failure 2° to ? active PTB ?CAP 

Recurrent hypoglycemia resolved, secondary to ? IAS , PTB 

P:

1) IVF- NS @ 30 ml/hr

2) TAB.ISONIAZID 75mg

     TAB.RIFAMPICIN 150mg

     TAB. PYRAZINAMIDE 400mg

     TAB. ETHAMBUTOL 275mg

     (3 TAB PO/OD)

3)ABG 6TH HRLY

4)BP/PR/RR/SPO2/GRBS CHARTING

5) AIR BED.