54/M with hiccups and altered sensorium

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Case : 

Pt c/o hiccups since 5 days 

up rolling of eyeballs and frothing since morning 

Chief complaints: 

54 year male came to casualty on 27-10-22 with complaints of hiccups since 5 days and up rolling of eyeballs and frothing since morning 

HOPI: 

Pt was apparently asymptomatic 5 days back then he had hiccups for 5 days 

He had up rolling of eyeballs and frothing since morning not associated with any involuntary movements or involuntary micturition 

Past history: 

He had similar episodes of hiccups 6 months back 

2 months back he was admitted in hospital and was found out to have hypokalemia 

K/c/o DM since 7 years 

( he had trauma 5 years back to foot which was not healing properly so he went to the hospital and was diagnosed as diabetic) 

Initially he took medication but his sugars were not under control 

Then he was switched to insulin under doctor’s advice 

20U in the morning and 15 units in the night since 3 months 

N/k/c/o HTN, asthma , epilepsy, cad, cvd 

H/o trauma to head ( Rta -bike skid) 1 month back he had a Laceration 

Personal history : 

Diet : mixed 

Appetite: normal 

Bowel and bladder habits: regular 

Addictions: none 

Sleep : adequate 

Family history: 

Insignificant 

General examination: 

Pt is conscious coherent and cooperative 

Delayed response 

Moderately built and nourished 

Pallor , icterus, cyanosis, clubbing , lymphadenopathy, edema are absent 

Vitals: 

Temp; 98

BP: 140/80

PR: 82 bpm

RR:20/min 

Systemic examination: 

CVS: s1 s2 heard 

        No murmurs 

Respiratory system; normal vesicular breath sounds are heard 

Abdomen: soft non tender no organomegly

CNS;

Higher functions:

Right handed 

Conscious 

Delayed response 

Oriented to time place and person 

Memory: recent- present 

              Immediate: present 

              Remote: present 

Speech: slurred 

Cranial nerve examination: normal 

Cerebellar system : 

Finger nose test : unable to do 

Knee heel test: unable to do 

Finger finger: unable to do 

Nystagmus: no 

Spinomotor system:

                                            Right              Left  

BULK:                 U/L-       Normal          Normal 

                            

                                      

                         L/L-           Normal          Normal 

                                

                  

TONE:             U/L           Normal           normal

                        L/L             Normal           normal

                          

                                           Right                Left 

POWER:      U/L-. hand 4/5                     4/5

                            - elbow 4/5                     4/5

                            - shoulder 4/5                4/5

                     L/L- hip 4/5                            4/5

                           - knee 4/5                         4/5   

                            - ankle 4/5                       4/5

                                       Right                       Left        

REFLEXES: Biceps -                                    -

                      Triceps -                                    - 

                    Supinator -                                  -

                         Knee +                                    +

                        Ankle -                                     -

                     Plantar Flexion                     Flexion 

4c) 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 

Investigations: 

Urinary potassium: 

Urine sodium :

Thyroid profile: 

LFT

Random Blood sugar : 

Hemogram

CUE

RFT

Ultrasound abdomen: 

Ultrasound chest : 

Chest X-ray: 

MRI brain : 

Provisional diagnosis: 

Altered sensorium 

? Hypoactive delirium secondary to dyselectrolytemia 

CKD ( diabetic nephropathy) 

Treatment : 

On 29-10-22

1) Iv fluids NS @30ml/hr 

2) inj pan 40mg iv OD 

3) syp potchlor 15ml in glass of water po tid