88/F with RECURRENT HYPOGLYCEMIA AND ADRENAL INSUFFICIENCY. HYPOVOLEMIC SHOCK 2° TO ACUTE GE(VIRAL TOXIN)

21/3/2023

A 88 yrs old Female presented to casualty with

C/o irrelevant talk and altered mental status since 3 hours.

Loose stools since yesterday (3 episodes)

HISTORY OF PRESENT ILLNESS:

Patient was asymptomatic till yesterday and then she developed loose stools,3 episodes watery in consistency, non blood stained non foul smelling. Pt was found unconcious, not responding to verbal commands and in altered sensorium and her speech being non cohorent .

2 D echo was done  

2 D echo ( CAD , LAD + territor) , Global Hypokinesia , Severe LV dysfunction 

No history of chest pain , palpitations , giddiness. 

No h/o weakness in both limbs and now developed hypoglycemia with grbs of 31mg/dl 

No h/o involuntary movements in both limbs

No h/o fever, vomiting's,  chest pain, sob

PAST HISTORY 

K/c/o HEART FAILURE with EJECTION FRACTION 42% secondary to ant wall MI

with PRE RENAL AKI AND RT LOWER LIMB CONSOLIDATION WITH URETHRAL CARUNCLE

N/ K/C/O HTN , DM , CVA , Epilepsy , Asthma

 

PERSONAL HISTORY: 

DIET: MIXED 

APPETITE: DECREASED 

BOWEL AND BLADDER MOVEMENTS: REGULAR 

SLEEP: ADEQUATE 

ADDICTIONS: NO

ON EXAMINATION :

PATIENT IS CONSCIOUS NON COHERENT AND COOPERATIVE 

GENERAL EXAMINATION:

NO PALLOR ICTERUS CYANOSIS CLUBBING LYMPHADENOPATHY EDEMA 

VITALS:

BP- 70/40 MMHG

PR- 116BPM

RR- 20CPM

SPO2- 95 @RA , 

GRBS- 31MG/DL

CVS- S1 S2 HEARD. NO MURMURS 

RS -Barrel shaped chest , BAE + 

        Crepts + , Left IAA ,ISA

       Bronchial breath sounds , 

        Right ISA 

       

PA - soft , nontender

TEMP - AFEBRILE 

CNS : Not oriented to Time, place

GAIT - NORMAL 

GCS- E4V5M6

Investigations 

Hb-7.9

Tlc- 9900

L-19

Pcv-260

Mch- 26.3

MCHC- 30.4

RBC-3.00

PLT-2.65

Na-132

K- 3.6

Cl-96

Ca-1.0

B urea-74

Sr creatinine-2.4

Updated fever chart as of 24/4/23

Treatment 

1. INJ 25% DEXTROSE 30ML/HR/IV

2. IV FLUIDS 0.9% NS @ 50ML/HR/IV

3. INJ. CIPROFLOXACIN 500MG IV/BD

4. INJ. METROGYL 500MG IV/TID

5. INJ PAN 40MG IV/OD

6. GRBS HOURLY MONITORING 

7. STRICT I/O CHARTING 

8. MONITOR VITALS.

23/3/23

ICU BED 4

S

NO FEVER SPIKES

STOOLS NOT PASSED

O

PT IS IRRITABLE

ORIENTED TO TIME PLACE AMD PERSON

Temp : 98.4

Pr : 84/min

BP: 70 /50 mmhg

Spo2 : 96% on RA

RR : 18/min

Cvs : s1s2+ no murmurs 

RS : bae+ ,nvbs

Cns : NAD 

GCS: E4V5M6

P/A : soft, non tender

A

Recurrent hypoglycemia under evaluation 

AkI (?PRERENAL 2° TO DEHYDRATION)

HYPOVOLEMIC SHOCK SECONDARY TO ACUTE GF (?VIRAL TOXIN)

HEART FAILURE WITH MID RANGE EJECTION FRACTION (42%) SECONDARY TO CAD (OLD AWMO) 

? ADRENAL INSUFFICIENCY 

P

1. Iv fluids NS @70ML/HR

2.INJ CIPROFLOXACIN 500MG IV BD (D2)

3. INJ METROGYL 500MG IV TID (DAY3)

4. TAB ECOSPRIN GLLD 75G PO OD

5.GRBS HOURLY MONITORING 

6. STRICT I/O CHARTING 

7. MONITOR VITALS 2ND HOURLY

24/4/23

ICU BED 4

S

NO FEVER SPIKES

STOOLS NOT PASSED

O

PT IS IRRITABLE

ORIENTED TO TIME PLACE AMD PERSON

Temp : 96.4

Pr : 74/min

BP: 90 /50 mmhg

Spo2 : 96% on RA

RR : 18/min

Cvs : s1s2+ no murmurs 

RS : bae+ ,nvbs

Cns : NAD 

GCS: E4V5M6

P/A : soft, non tender

A

Recurrent hypoglycemia under evaluation 

AkI (?PRERENAL 2° TO DEHYDRATION)

HYPOVOLEMIC SHOCK SECONDARY TO ACUTE GF (?VIRAL TOXIN)

HEART FAILURE WITH MID RANGE EJECTION FRACTION (42%) SECONDARY TO CAD (OLD AWMO) 

? ADRENAL INSUFFICIENCY 

P

1. Iv fluids NS @70ML/HR

2.INJ CIPROFLOXACIN 500MG IV BD (D3)

3. INJ METROGYL 500MG IV TID (DAY2)

4. TAB ECOSPRIN GLLD 75G PO OD

5.GRBS HOURLY MONITORING 

6. STRICT I/O CHARTING 

7. MONITOR VITALS 2ND HOURLY