Case discussion: Decrease consciousness
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Transcript of Case discussion: Decrease consciousness
CASE DISCUSSION:DECREASE CONSCIOUSNESS
Pratama Wicaksana Narissa Dewi MaulanyMona JamtaniKing HansNurul LarasatiMargaretha GunawanSupervisors: Prof. Sarwono & Prof
Case Illustration
Patient Identity
Name: Mr. R Gender: Male Age: 47 years old Religion: Islam Address: Jl. Mardani Raya Gg. T/41 RT
003/005, Johar Baru, Jakarta Pusat Medical record number: 345-94-82 Date of admission: December 27th 2010.
Chief Complaint
Decrease of consciousness since 14 hours prior to hospital admission.
History of Present Illness
3day
s PTH
A general weaknesses, pt can’t walk thus needed help to mobilize. The weaknesses was felt at the same intensity on the four extremities. There was also decrease of appetite (pt only drink and eat a bit of porridge), no mouth deviation and no slurred speech was noticed. Pt also complained of shortness of breath, on exertion and at rest. There was no chest pain.
14H
PTHA
patient started to talk unaccordingly, not being able to communicated with, and looked drowsy as if he was going on a sleep, then pt. was brought to the hospital. There was a complain of headache and nausea, patient vomited 2 times which were consisted of food and water. There was no problem with voiding, and the last defecation was 4 days ago.
Othe
r Com
plai
nts Symptoms of
frequent eating, urinating, and sleepiness has been noticed by his wife daily, but there was no numbness, tingling sensation, nor persistent wound complained by the patient.
Past history of illness
History of type II DM since 5 years ago: does not take medicine regularly and does not know the type of drugs
Hypertension since 3 years ago: was on captopril-taken regularly and regular visit to the physician
no asthma, no history of lung disease or Anti TB drugs, no history of previous stroke, and no history of drug allergy
Family history of illness There was no familial history of
hypertension, asthma, heart disease, lung disease, and allergy
Social and working history Patient smoked for 30 years, but has
stopped smoking since 4 months ago
on admission to the Emergency Department (27/12/2010)
Physical Examination
Physical Examination
Vital signs
Consciousness: spoor, GCS: E2M4V2 = 8
General condition: look severely ill
Blood pressure: 80/60 mmHg
Pulse: 110x/minute, weak Temperature: 36.70C
(axilla temperature) Respiratory rate:
32x/minute, fast and deep
Skin : Not pale, not cyanotic, not icteric Head : Normochepal. Hair : Black, not easily pulled Eyes : Pale conjunctiva (-/-), icteric sclera
(-/-), Round pupil, isochor, diameter 3mm, direct light reflex +/+, indirect light reflex +/+.
Ears : Auricula N/N, tymphanic membrane intact, no cerumen.
Nose: No deviation of septum Throat : Tonsil T1/T1 calm, pharyngeal
arch symmetrical, uvula in the middle, pharynx not hyperemic.
Teeth and mouth: no caries, no oral thrust
Neck: Trachea in the middle, JVP 5-2 cmH2O, lymph node was not palpable, no mass, Meningeal signs: neck stiffness (-), Laseque >70o />70o, Kernig >135o/>135
Physical Examination
Lungs Inspection : symmetrical,
static and dynamic. Palpation : fremitus are same
in both lungs Percussion : sonor on all
lung fields. Auscultation : Vesicular
(+/+), no rhales, no wheezing.
Back: symmetric in static and dynamic movement, sonor, vesicular, no rhales and no wheezing
Heart Inspection : Ictus cordis is
not visible Palpation : ictus cordis is
palpable at ICS 5, on the mid clavicular line
Percussion : right heart border at linea sternalis dextra, upper heart border at ICS III linea para sternalis sinistra, and left heart border at 3 fingers lateral from linea mid clavicularis sinistra.
Auscultation : Normal first and second heart sound, no murmur, no gallop.
Physical Examination
Abdomen Inspection : flat,
supple. Palpation : hepar and
spleen is not palpable Percussion :
tymphanic (+) Auscultation : Bowel
sound (+), normal. Genitals: not performed.Rectal touché: not
performed.
Extremities: warm, CRT >2”, no edema,
Motoric reflex: no hemiparesis, physiological reflex: +2/+2, +2/+2 pathological reflex: none
Sensoric reflex: can’t be assessed
Autonomic reflex: no urinary or defecation incontinence
Lymph nodes: There was no palpable lymph node enlargement
Summary
Patient a gentleman aged 47yo came with chief complaint of decrease consciousness since 14hours prior to hospital admission. Since 3 days before hospital admission, patient has been complaining of general weaknesses which was felt at the same intensity on the four extremities. There was also decrease of appetite. Pt also complained of shortness of breath, on exertion and at rest. 14 hours prior to hospital admission, patient started to talk inaccordingly, not being able to communicated with, and looked drowsy as if he was going on a sleep, then pt. was brought to the hospital. There was a complain of headache and nausea, patient vomitted 2 times which were consisted of food and water. Symptoms of frequent eating, urinating, and sleepiness was noticed by his wife. Patient has history of type II DM since 5 years ago: does not take medicine regularly and does not know the type of drugs, hypertension since 3 years ago: was on captopril-taken regularly and regular visit to the physician. Patient smoked for 30 years, but has stopped smoking since 4 months ago. Laboratory results showed leukocytosis, increase plasma ureum and creatinine, very high level of blood glucose, hypokalemia, metabolic acidosis, and positive plasma ketone 3-hydroxybutyrate.
Problem list: Decrease of consciousness ec hypovolemic shock ec
Diabetic Ketoacidosis Diabetic Ketoacidosis on DM Type II with history of
uncontrolled blood glucose Dyspepsia with difficulty of intake
Plan Diagnosis plan: ECG, chest x-ray CBC, diff count, electrolytes, arterial blood gas analysis,
keton 3Hb, blood chemistry, urinalysis, Brain CT
Laboratory ExaminationPeripheral blood test (28/12/2010):
Result Normal rangeRoutine hematologyHaemoglobin 12.6 (↓) 12-14 g/dLHaematocryte 37 40-46 %Leukocyte 14.300 (↑) 5.000-10.000 /uLThrombocyte 167.000 150.000-400.000 /uLMCV 85 82-92 fLMCH 29 27-31 pqMCHC 34 32-36 10^3/uL
Blood chemistryBlood Ureum 179 (↑) <50 Mg/dLBlood Creatinine 1.7 (↑) 0,6-1,2 Mg/dLBlood Glucose Stick High 70-200 Mg/dL
Laboratory ExaminationPeripheral blood test (28/12/2010):
Electrolytes
Natrium 131 135-147
Kalium 6.2(↑) 3.5-5.5
Chloride 106 100-106
Arterial Blood Gas Analysis
pH 7.091() 7.320-7.450
PCO2 19.7() 35-45
PO2 154(↑) 75-100
SO2 98.6
HCO3 6.1 21-25
Keton 3Hb 2.8 <0.5
Treatment plan: O2 2 litre/ minute per nasal cannule Loading NaCl 0.9% up to 3000cc, MAP target >65
Followed by NaCl 0.9% in 8hour Haemacel in 12hour
Insulin: 10IU IV followed by 5IU/hour drip HCO3 50meq/6H Folley Catheter: Fluid Balance in 24H Omeprazole 1x40mg IV Prognosis: Quo ad vitam: Dubia ad bonam Quo ad functionam: dubia ad bonam Quo ad sanactionam: Dubia ad malam
CASE DISCUSSION
Decreased consciousness et causa Hypovolemic Shock et causa Diabetic Ketoacidosis
Decreased consciousness et causa hypovolemic shock
Decreased conciousnessGCS 8Hemiparesis (-)
Shock80/60 mmHg, 110x/minute inadequate
volume , 32x/minute ,d
eep, (kussmaul)T: 36,7OC
Fever (-), focus of infection (-) sepsis
excluded. hemorrhage (-),
dehydration, diarrhea (-)
excluded History of heart
disease (-) excluded
Fluid resuscitation
good response shock
hypovolemia, suspect metabolic
condition.
Diabetes Mellitus History
History of diabetes mellitus type 2,
didn’t take medication regularly
Polyuria(+), polydipsy (+), polyfagi (+),
weight loss (+)
Recent history: general weakness, anorexia, lethargy, and decreased of consciousness
Suspect Diabetic
Ketoacidosis
Planing: blood
glucose test, urinalysis, blood gas
analysis, and ketone
Working Diagnosis
Glycemia > 500mg/dl, ketone
3HB 2.8 mg ↑. blood PH is 7,09↓, PCO2 19.7↓, PO2
154 ↓, HCO3 6,6↓,
Decreased consciousness et
causa Hypovolemic
Shock et causa Diabetic
Ketoacidosis
Pathophysiology DKA
Glukagon↑Insulin↓↓
Fat tissue
lipolysis↑↑
Liver ketogene
sisLiver
glukoneogenesis
Peripheral tissue glucose
consumption ↓↓
osmolarity↑↑Acidosis (ketosis)
Hypovolemic Shock in Ketoacidosis DM
hyperglycemia and ketone
vascular osmolarity ↑↑
(Osmotic ) Diuresis ↑↑
polyuria, electrolyte losses, dehydration,
and eventually hypovolemia shock
Metabolic Acidosis
Lipolysis & ketogenesis
ketone 3HB & acetoacetate in
circulation ↑
Unable to buffer PH↓↓
Ion exchange across cell membranes intracellular acidosis alter abnormal
celular metabolism
Metabolic acidosis
Encephalopathy Metabolic
acidity↑↑ PCO2↓↓
Vasodilatation of vascular
brain
Leakage of vascular volume
increase Intracranial Pressure
Decrease of consciousness
Management of Fluid Resucitation fluid resuscitation 3000cc in 3hour
to reach the MAP of >65 (in 3h BP of 90/65 was achieved fluid replacement was then continued for another 1000cc in 4 hours reaching BP of 120/80 (MAP:120), continue with maintenance fluid
Management of Hyperglicemia Insulin IV initially 10IU for the very
high blood glucose concentration (>500g/dL) then followed by continuous IV 5IU/hour. In 7hours, blood glucose level of 178g/dL was achieved patient consciousness developed to delirium.
Management of abdominal dyscomfort
abdominal discomfort & prevent recurrent vomit omeprazole 2x40mg IV was given.
References
1. Faucy, et al. Harrison’s principle of internal medicine. 17th ed. USA: McGraw-Hill Company Inc; 2008. P: 721-780.
2. Warrel, et al. Oxford Textbook of Medicine. 4th ed. USA: Oxford Press; 2003. P: 220-225
3. Rucker, Donald. Diabetic ketoacidosis. Emergency medicine. www.emedicine.medscape.com. 2009.
4. Sudoyo AW, Setiyohadi B, Alwi I et al. Buku Ajar Ilmu Penyakit dalam. Jilid III Edisi V. Interna Publishing. 2009. P: 1849-1882.
5. Ronco, Claudio, Et al. Acute kidney injury. Pittsburgh: Karger. 2007. P: 89-92.