A 80 year old male in unresponsive state

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This is an online E - log book to discuss our patients de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online portfolio and your valuable inputs on the comment box.


14/9

A 80 year male presented to casuality in a unresponsive state at around 7 am

History of presenting illness:

Patient was apparently asymptomatic one day back. At about 1 to 2 am he woke up and then he himself heated milk and mixed it with the rice and had consumed the meal. He then slept.
Then around 4 am he tried to wake his wife but she was in a deep sleep. Later she woke up and found him laying at bed side and with the help of his relatives they took him to near by government hospital where he was on IVF DNS and Oxygen mask @ 4 liters/min.


He was later brought to casuality in our hospital at around 7 am


Past history : 

1 week ago history of weakness and fever
Visited local RMP and was given medications.





QMAX - Ofloxacin tablet IP 200mg

Megapen - Ampicillin and cloxacillin capsule 250/250mg



1 to 2 years ago history of cough with no sputum, fever - all day (persistent fever) for which he visited local RMP. He was on medications which he took for 1 week till symptoms - TB?


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


Personal history:

Diet : mixed 
Appetite: normal
Sleep : regular
Bowel and bladder: regular
No addictions

General examination:

Patient was concious, unresponsive
No pallor, Icterus, clubbing, cyanosis, edema , lymphadenopathy

Vitals:

Temp. 98.3°F 
BP - 160/90mmHg
PR- 88bpm
CVS- S1 S2 + , loud s2
RS- BAE +
P/A- soft. NT
SpO2 -
1) 83 % at room air
2) 98% on 8L of O2
GRBS -42mg/dl 

Provisional diagnosis: 

Type 2 respiratory failure secondary to PTB (clinicoradiological) with recurrent hypoglycemia (resolved) secondary to? TB

Investigations : 


14/09/22

ABG 1

 ABG 2

LFT

RFT 
ECG

 HBsAg

Hcv   

HIV ELISA

Chest x-ray 

2D ECHO

USG ABDOMEN


15/09/22

ABG 1

                            
ABG 2

ABG 3

16-09-2022

ABG 1

ABG 2

ABG 3

ECG

17-9-2022


ABG 1


ABG 2

ABG 3 


18-09-2022


ABG 1


ABG 2


ABG 3

ABG 4

19-09-2022




ABG 1


ABG 2

20-09-2022

ABG

21-09-2022





22-09-2022

ABG 1

ABG 2


23-09-2022


Fever chart:



Daily vitals monitoring:





14-09-22

1) Inj 25% Dextrose/IV/ @ 40ml/hr
2) NEBULIZATION T DUOLIN 6th hrly, BUDECORT 8th hrly
3) Bipap intermittently for 2 hrs


15-09-22

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. 
5) Bipap intermittently for 2 hrs


16-09-22

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 hourly
8) AIR BED. 
9) Position change 2nd hourly
10) ABG 6th hourly

17-09-2022

1) IVF- NS 30 ml/hr
2) INJ. LASIX 20mgIV/BD 
3) Tab Isoniazid 75 mg
    Tab Rifampicin 150 mg
    Tab Pyrazinamide 400 mg
    Tab ethambutol 275 mg
-- 3 tab/PO/OD
4) Air bed
6) Position change 2nd hourly
7) ABG 6th hourly


18-09-2022

1) IVF- NS 30 ml/hr
2) INJ. LASIX 20mgIV/BD 
3) Tab Isoniazid 75 mg
 Tab Rifampicin 150 mg
 Tab Pyrazinamide 400 mg
Tab ethambutol 275 mg
-- 3 tab/PO/OD
4) Air bed
5) Position change 2nd hourly
6) ABG 6th hourly


19-09-2022

1) IVF- NS 30 ml/hr
2) INJ. LASIX 20mgIV/BD 
3) Tab Isoniazid 75 mg
Tab Rifampicin 150 mg
 Tab Pyrazinamide 400 mg
Tab ethambutol 275 mg
-- 3 tab/PO/OD
4) Air bed
5) Position change 2nd hourly
6) ABG 6th hourly


20-09-2022

1) IVF- NS 30 ml/hr
2) INJ. LASIX 40mgIV/BD 
3) Tab Isoniazid 75 mg
Tab Rifampicin 150 mg
 Tab Pyrazinamide 400 mg
Tab ethambutol 275 mg
-- 3 tab/PO/OD
4) Air bed
5) Position change 4th hourly
6) ABG 6th hourly


21-09-2022

1) IVF- NS 30 ml/hr
2) INJ. LASIX 40mgIV/BD 
3) Tab Isoniazid 75 mg
Tab Rifampicin 150 mg
 Tab Pyrazinamide 400 mg
Tab ethambutol 275 mg
-- 3 tab/PO/OD
4) Air bed
5) Position change 2nd hourly
6) ABG 6th hourly


23-09-2022

1) IVF- NS @ 50 ml/hr
2) INJ. LASIX 20mgIV/BD
3) Oxygen therapy 2 to 4 liters
Intermittent Bipap 
4) Tab Isoniazid 75 mg
Tab Rifampicin 150 mg
 Tab Pyrazinamide 400 mg
Tab ethambutol 275 mg
-- 3 tab/PO/OD
5) BP/temp/ SpO2/ RR/ GRBS charting 4th hourly
6) Inform SOS

24-09-2022

1) IVF- NS @ 50 ml/hr
2) O2 inhalation to maintain SpO2 at or more 92%
3) Tab Isoniazid 75 mg
Tab Rifampicin 150 mg
 Tab Pyrazinamide 400 mg
Tab ethambutol 275 mg
-- 3 tab/PO/OD
4) Inform SOS
5) Intermittent Bipap

A special thanks to: (refered from)

http://02shishirareddy.blogspot.com/2022/09/80-year-old-male-pt.html

https://manvisharma88.blogspot.com/2022/09/80-yo-male-with-hypoglycemia.html

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