A 54yr old male with hiccups

 31/10/22

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CHIEF COMPLAINTS:

27/10/22:

A 54 year old male presented to casualty in altered state with hiccups since 5days, uprolling of eyeball and frothing since morning i.e., on 27th oct (day of admission).

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 22yrs back after which he started consuming tobacco in the form of chewing ghutka. Initially he used to consume 1packet/day which gradually progressed to 8packets everyday currently.

Patient is currently in drowsy state,he denies any cravings for tobacco and any withdrawals.

OD reports that patient has cravings for tobacco, she also reports that he has irritability,headache and constipation, whenever he doesn't consume tobacco.

Patient was brought to casualty on 27th oct at around 10am in the morning, i/v/o seizure like activity associated with drooling and loss of consciousness.

OD also reports that he is also having history of hiccups since 5days and also had similar episodes of continuous hiccups were present 6months and 2months back for which he was admitted in the hospital and was found to have hypokalemia.

He also had excessive drowsiness since 2days which was sudden in onset and also had uprolling of eyeball and frothing since morning i.e.,on 27th oct.

He also had one fever spike yesterday I.e., on 31/10/22.

PAST HISTORY:

He had a history of trauma to foot 5yrs back which was not healing properly so he went to hospital and found to have DM and on insulin therapy

He had similar episodes of that tobacco dependence syndrome in the past once a year ago and once 2months back.

History of alcohol consumption for 10years and abstinent since past 10yrs.

No history of hypertension, asthma, TB, CAD and CVD

Previously he had psoriasis

FAMILY HISTORY:

No significant family history.

PERSONAL HISTORY:

Diet:Mixed

Appetite:Normal

Sleep: Adequate

Bladder movements were regular but bowel movements were irregular

He had history of constipation since 6yrs

Addictions: History of chewing ghutka since 22yrs.

GENERAL EXAMINATION

Patient is not conscious at the time of admission but he is little bit drowsy now and responding to oral commands. He is moderately built and moderately nourished.

Pallor:absent

Icterus: absent

Cyanosis:absent

Clubbing:

Generalized lymphadenopathy:absent 

Pedal edema:Absent

VITALS:

Temp:fever spike is present yesterday(100.2°F)

Pulse rate:84bpm

Blood pressure:160/80mmhg

Respiratory rate:16cpm

SpO2:98%on room air

SYSTEMIC EXAMINATION

1)HIGHER MENTAL FUNCTIONS

Patient is conscious,coherent and cooperative

Right handed person

MMSE - 30/30

Nystagmus -absent

Speech - spontaneous with intact naming, repetition,fluency.

Spine –normal

Cranium –normal

gait -ataxic gait

    

2)CRANIAL NERVES -  right.         Left

1.Sense of smell - normal.   Normal

2.Visual acuity - normal.      Normal

Field of vision- normal.        Normal

colour vision. Normal.          Normal

fundus.            Normal.          Normal

3,4,6 : extra ocular movements:Normal

-pupils: Normal size and reacting to light on both sides

-direct and consensual light reflexes normal in both eyes

No Nystagmus

no ptosis

5. Sensory : sensations over face normal on both sides

 Motor - massater,temporarils, pterygoids normal

7. Motor : Nasolabial fold,Orbicularis oculi, orbicularis Oris ,occipital frontalis, 

buccinator -normal on both sides

 Sensory : taste over anterior 2/3rd of tongue normal on both sides

8. Rinnes test normal on both sides

. Webers test normal on both sides

9.10. Uvula , palatal arch movements normal.

Gag reflex. - normal

Palatal reflex - normal

11. Tarpezium and sternocleidomastoid -normal

12. No wasting and fasciculations of tongue

Tongue protrusion to midline.

3)MOTOR SYSTEM

I  BULK.                  Right             Left

        Upper limb  Normal.        Normal

        Lower limb   Normal.        Normal

II  TONE

      Upper limbs.   Normal.      Normal

       Lower limbs.   Normal.     Normal

III  POWER

A}Neck muscles.   Good      Good

 B} Upper limbs.  

                Shoulder  4/5.    4/5

                Elbow:.     4/5.        4/5

                Wrist:-.    4/5.         4/5

C}Lower limbs.        Right.       Left

         1) Hip                4/5.         4/5

         2)Knee.             4/5.       4/5

         3)Ankle             4/5.       4/5

IV.REFLEXES

Left

        1)Biceps jerk         Absent.      Absent

        2)Triceps jerk        Absent.      Absent

        3)Supinator jerk.   Absent.      Absent

       4)Knee jerk.           Present.      Present

       5)Ankle jerk           Absent.      Absent

       6)Plantar.                Flexion.     Flexion

4)SENSORY SYSTEM EXAMINATION: As patient is drowsy examination of sensory system is limited 

                                          Right                    Left  

• crude touch              present      present
• fine touch                      -                   -               
• pain                            Present      present
• Temperature              Present.    Present 
• Vibration                      Couldn’t be elicited                            
• stereognosis-               Present    present 
• 2 pt discrimination-          -                - 
• Proprioception            Couldn’t be elicited                                   
• Graphesthesia             Absent.  . Absent 

5) CEREBELLAR SYSTEM: 

-Finger nose test : unable to do 

-Knee heel test: unable to do 

-Finger finger: unable to do 

-Nystagmus: no 

CARDIOVASCULAR SYSTEM:

S1 S2 heard no murmurs

RESPIRATORY SYSTEM:

Normal vesicular breaths sounds heard and no added breath sounds.

GIT:

No abnormalities

INVESTIGATIONS:

Haemogram:

CUE:

Urine potassium

Urine sodium:

Urine chloride:

Thyroid profile:

-LFT:

Random blood sugar:

RFT:

CXR:

ECG:

USG-CHEST:

minimal right pleural effusion

USG-ABDOMEN:

Gall bladder:partially distended

Raised echogenicity of bilateral kidneys

MRI brain:

PROVISIONAL DIAGNOSIS:

ALTERED SENSORIUM UNDER EVALUATION AND HYPOACTIVE DELIRIUM  

2°TO DYSELECTROLYTEMIA (HYPOKALEMIA)

CKD(DIABETIC NEPHROPATHY)

TREATMENT:

1)IV FLUIDS NS@100ml/hr

2)INJ.OPTINEURON 1AMP IN 100ML NS/IV/OD

3)SYP.POTKLOR 10ml in glass of water/PO/TID

4) TAB.CINOD 10mg/PO/OD

5)MONITOR VITALS 

6)SALT RESTRICTION-<2.5gm/day.