1 / 29

Case discussion: Decrease consciousness

Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof. Case discussion: Decrease consciousness. Case Illustration. Patient Identity. Name: Mr . R Gender: M ale Age: 4 7 years old Religion: Islam

misha
Download Presentation

Case discussion: Decrease consciousness

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan Supervisors: Prof. Sarwono & Prof Case discussion:Decrease consciousness

  2. Case Illustration

  3. 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.

  4. Chief Complaint • Decrease of consciousness since 14 hours prior to hospital admission.

  5. History of Present Illness

  6. 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

  7. 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

  8. Physical Examination on admission to the Emergency Department (27/12/2010)

  9. 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

  10. 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 lineasternalisdextra, upper heart border at ICS III lineaparasternalissinistra, and left heart border at 3 fingers lateral from linea mid clavicularissinistra. • Auscultation : Normal first and second heart sound, no murmur, no gallop.

  11. 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

  12. 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.

  13. Problem list: • Decrease of consciousness echypovolemic 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

  14. Laboratory ExaminationPeripheral blood test (28/12/2010):

  15. Laboratory ExaminationPeripheral blood test (28/12/2010):

  16. 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

  17. Case Discussion

  18. Decreased consciousness et causaHypovolemic Shock et causa Diabetic Ketoacidosis

  19. Decreased consciousness et causahypovolemic shock Decreased conciousness GCS 8 Hemiparesis (-) Shock 80/60 mmHg,110x/minute inadequate volume , 32x/minute ,deep, (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.

  20. 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 Planing: blood glucose test, urinalysis, blood gas analysis, and ketone Suspect Diabetic Ketoacidosis

  21. 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 causaHypovolemic Shock et causa Diabetic Ketoacidosis

  22. Pathophysiology DKA Glukagon↑ Insulin↓↓ Fat tissue lipolysis↑↑ Liver ketogenesis Liver glukoneogenesis Peripheral tissue glucose consumption ↓↓ Acidosis (ketosis) osmolarity↑↑

  23. Hypovolemic Shock in Ketoacidosis DM hyperglycemia and ketone vascular osmolarity ↑↑ (Osmotic ) Diuresis ↑↑ polyuria, electrolyte losses, dehydration, and eventually hypovolemia shock

  24. Metabolic Acidosis Lipolysis & ketogenesis ketone 3HB & acetoacetate in circulation ↑ Ion exchange across cell membranes  intracellular acidosis  alter abnormal celular metabolism Unable to buffer PH↓↓ Metabolic acidosis

  25. Encephalopathy Metabolic Vasodilatation of vascular brain acidity↑↑ PCO2↓↓ Leakage of vascular volume increase Intracranial Pressure Decrease of consciousness

  26. 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

  27. 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.

  28. Management of abdominal dyscomfort • abdominal discomfort & prevent recurrent vomit  omeprazole 2x40mg IV was given.

  29. References • Faucy, et al. Harrison’s principle of internal medicine. 17th ed. USA: McGraw-Hill Company Inc; 2008. P: 721-780. • Warrel, et al. Oxford Textbook of Medicine. 4th ed. USA: Oxford Press; 2003. P: 220-225 • Rucker, Donald. Diabetic ketoacidosis. Emergency medicine. www.emedicine.medscape.com. 2009. • Sudoyo AW, Setiyohadi B, Alwi I et al. Buku Ajar Ilmu Penyakit dalam. Jilid III Edisi V. Interna Publishing. 2009. P: 1849-1882. • Ronco, Claudio, Et al. Acute kidney injury. Pittsburgh: Karger. 2007. P: 89-92.

More Related