Pratama Wicaksana Narissa Dewi Maulany Mona Jamtani King Hans Nurul Larasati Margaretha Gunawan...

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

3days

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

PTH

A 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.

Oth

er

Com

pla

ints

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 range

Routine hematology

Haemoglobin 12.6 (↓) 12-14 g/dL

Haematocryte 37 40-46 %

Leukocyte 14.300 (↑) 5.000-10.000 /uL

Thrombocyte 167.000 150.000-400.000 /uL

MCV 85 82-92 fL

MCH 29 27-31 pq

MCHC 34 32-36 10^3/uL

Blood chemistry

Blood Ureum 179 (↑) <50 Mg/dL

Blood Creatinine 1.7 (↑) 0,6-1,2 Mg/dL

Blood 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

sis

Liver glukoneogen

esis

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.