65 YR OLD MALE WITH ALTERED BEHAVIOUR AND WEAKNESS

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I have 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.

 A 65 yr old male resident of ersanigudem , daily labourer by occupation came with 

Chief complaints : 

Altered sensorium since  20 days 

Generalised weakness since 20 days 

Daily routine : 

Before illness ( 4 yrs back)

He gets up from bed at 5 am does his daily routine freshen up and then goes to his daily work like Wood work , sand work and then goes to farming ( vari natadam) and works upto 9 am and then have rice as his breakfast and then again works at the field upto 1 pm and then has lunch takes rest for 1 hr and then works at field upto 5 pm and then goes to home and takes bath and rests for some time and then has his dinner at around 8 : 30 pm and then goes to rest .

After illness : 

Since 4 yrs after he has been diagnosed with Dm and Htn , he feels weakness and not having enough strength for working and stopped going to work and just stays at home all the time has his breakfast lunch dinner and sometimes goes to walk around the village for chatting with neighbours and other villagers . 

HOPI : 

2020

Patient was apparently asymptomatic 4 yrs back the he had fever for 1 week and also at fine morning at 2 am he had suddenly fell from the bed and was lifted and made to sleep on the bed and also again at 5 am he again fell down from the bed where they felt suspicious and was taken to local hospital  was on investigating he was diagnosed with DM and HTN was admitted for 3 days , insulin was given and has been on medication ? Since then and then was apparently normal.

He stopped going to work since then and just sits and home idle as he feels weakness and body pains and difficult in bending and doing work

2021 

Since 2 yrs he also had lower backache for which he used some medications ( analgesics? ) and had neglected it and no investigation or treatment has been done for that . 

2023 

20 days back he developed altered behaviour at morning started scolding his wife but his speech was not clear and has also been weak and was taken to local hospital at nakrekal and was investigated and his blood sugar levels were low and renal parameters were deranged was admitted for 3 days and was diagnosed as CKD and was advised for dialysis and then went home was fine for a week and then had been taken for nalgonda for medicine and dialysis and as there was no availability of dialysis there was reffered to our hospital.

They visited our hospital and was advised to return back after a day due to some reasons and was taken home and then he started having lower limb weakness was unable to walk long distance and suddenly at 15.06.23 morning there was no speech and movements from the patient and was brought to our hospital on checking his GRBS was 20mg/dl and was admitted.

H/o increased frequency of micturition , pain during micturition 

No H/o burning micturition , hematuria , any urge for micturition,

No h/o palpitations,sweating, orthopnea, pnd 

No h/o Fever,cough, cold .

Past history: 

Known case Of DM since 4 yrs , HTN since 4 yrs and is medication ? Since then .

H/o fistulectomy 5 yrs back . 

No h/o Tb, Asthma, epilepsy,CAd, thyroid disorders . 

Personal history: 

Patient is daily labourer by occupation stopped working since 4 yrs on being diagnosed with DM and HTN and was married 45 yrs back and Has no Children , His 1st boy child was born and died with 1 day of birth , His 2 nd girl child was born after 4 yrs after 1st pregnancy and died with 2 months after birth. 

Diet - Mixed

Sleep - Adequate

Appetite- Decreased since 20 days 

Bowel and bladder movemnts- Decreased bowel movements since 7 days 

Addictions: He has habit of drinking toddy everyday since 22 yrs of age and has habit of drinking alcohol occasionally at functions (180ml ) 

Has no smoking habits 

No h/o any allergies . 

General examination: 

Patient is Consious , non coherent, cooperative , mod built and mod nourished .

Pallor is present 

Pedal edema was present at time of admission but now it has subsided 

No Icterus, Cyanosis, Clubbing, Lymphadenopathy

Vitals: 

Bp: 150/80 mmHg

PR : 80 bpm

RR: 25 cpm

Temp: Afebrile 

GRBS: 87 mg /dl

Systemic examination : 

Per Abdomen : 

Inspection : 

Abdomen distended

Umbilical hernia is present 

No scars engorged veins

No visible peristalsis , pulsations 

No discoloration of skin 

PALPATION : 

Abdomen is non tender , no rise of temperature, no tenderness

No organomegally 

Liver and spleen non palpable 

PERCUSSION: 

Upper border of liver dullness is felt at 6th ICS along mid clavicular line and lower border non felt due to distended abdomen. 

No fluid thrill

Shifting dullness is present 

AUSCULTATION: 

Bowel sounds are present 

RESPIRATORY EXAMINATION:

INSPECTION: 

Shape elliptical 

Equal movements on both side 

Keloid scar is present 

No sinuses engorged veins pulsations 

Trachea appears central

PALPATION: 

Trachea central 

B/L sym chest expansion 

Vocal fremitus is normal on both sides 

PERCUSSION: 

Resonant note heard over all areas both sides 

AUSCULTATION: 

NVBS b/L

CVS EXAMINATION:

INSPECTION : 

Shape of chest symmetrical 

No engorged veins , no visible pulsations 

JVP not elevated 

PALPATION: 

Apex beat felt at 5 ics

No thrills and Heaves felt 

AUSCULTATION: 

S1 s2 heard no murmurs 

CNS EXAMINATION:  

Conscious non coherent cooperative 

Higher mental function - intact 

Cranial nerves  intact 

Sensory - normal 

Motor- 

Tone normal 

Power B/L 4/5 

Reflexes: Right , left 

      Biceps +     +

      Triceps +    +

       Supinator +   +

       Knee      +     +

Local examination of spine : 

SLRT : Negative 

Gait video : 

Diagnosis: 

Hypoglycaemia sec to OHA? 

Chronic renal failure , Anemia sec to CKD ?

K/c/o Dm and Htn since 4 yrs 

Investigations : 

Hemoglobin 

16/06 8.2gm/dl 

17/06 7gm/dl 

18/06 10.4gm/dl

19/06 8.6gm/dl

20/06 8.8gm/dl 

Blood urea 

16/06 104mg/dl 

17/06 124 mg/ dl 

Serum creatinine 

16/06 5.9 mg/ dl 

17/06 7.1mg/ dl 

21/06/23

Ophthal referral 

ECG : 

 USG: 

Treatment : 

Fluid restriction <2 L / day 

Salt restriction < 2g/ day 

25% dextrose infusion @ 25 ml/hr acc to GRBS * 2 days 

Inj lasix 40 mg IV /BD 

Tab Nicardia 20mg /PO/TID 

Tab .Arkamin 0.1mg PO/TID 

Tab orofer XT PO / BD 

Tab shelcal 500mg PO / OD 

Tab Nodosis 500 mg PO/BD