Case of a 78 year old male with altered sensorium

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Neha Tipparaju 

Roll no. 100

Case of a 78 year old male with altered sensorium 

My case is of a 78 year old male, resident of Ramanpet, who used to be a farmer by occupation. 

The patient was brought to casuality with altered sensorium after a fall. 

(Timeline of events) 

5 years back, the patient had a mild fever for which he was taken to a hospital. On screening there, he was found to be Type 2 diabetic and started on medication Tab. Metformin 500mg OD.

3 years back, he was found to be hypertensive and started on Tab Atenolol 50 mg OD.

He took medications regularly and was mostly assymptomatic ( blurring of vision, was adviced spectacles: presbyopia?)

25 days back he had a thorn prick injury to his left foot, below the second toe. He ignored this and it grew to ulcerate.

10 days back, the left foot was surgically debrided and dressed

History of presenting illness:

At 6 pm on 8/1/22, The patient had fallen from the bed due to loss of balance,his head hitting the corner of the table and hence sustained an injury on his left frontal region, near the left eyebrow.

He was fine for an hour after the fall. However, after 1 hour, he suddenly stopped responding to his family's questions, had breathlessness and palpitations, tremors,anxiety, was sweating profusely and was drowsy.

He was brought to the casuality. His vitals showed:

Heart rate: 115 BPM 

Respiratory rate: 22 cycles/ min 

Blood pressure: 210/ 120 mmHg 

Temperature: Afebrile

SPO2: 78% 

Random blood sugar: 40 mg/ dl 

• On examination, His Glasgow coma score was 11.

Eye opening was spontaneous (4)

He was confused, did not response verbally (4)

Was in a flexed posture (3)

• Inspiratory crepitations were heard in all the lung fields.

He was given O2 supplementation at 15 mL/hour and 25% dextrose i.v stat. He recovered and began to respond to commands. 

He sustained an injury to right 5th toe at night while walking to the washroom and this was appropriately dressed.

Presently, the patient is not complaining of any nausea, sweating, tremors, palpitations or headache.

He is not complaining of any chest pain, orthopnea, PND, swelling of limbs or any cough 

No complaints of change in urinary frequency (decrease or increase), no fever, suprapubic pain or burning micturition 

No complaints of blurring of vision, weakness for moving limbs, bowel and bladder incontinence

No fever, headache, vomiting or neck rigidity

Past history: 

There were no similar episodes in the past. K/c/o Diabetes since 5 years and hypertension since 3 years. Not a k/c/o asthma, tuberculosis, epilepsy, coronary artery disease or cerebrovascular accidents.

No surgeries in the past 

Drugs: Tab. Metformin 500 mg OD for 5 years 

Tab. Atenolol 50 mg OD for 3 years.

Personal history: The patient takes a mixed diet. Appetite is reduced and bowel and bladder are regular. He gets an adequate amount of sleep. No known allergies.

He used to smoke beedi everyday for 30 years, before he stopped 10 years back.

He occassionally drinks 60ml of toddy.

Family history: no relevant family history 

General Examination: Patient is examined in a well lit room after obtaining informed consent. He is conscious, coherent and cooperative, thinly built and nourished. 

On examination: 

Pallor: Moderate 

Icterus, cyanosis, clubbing, koilonychia, generalized lymphadenopathy or edema are not observed. 

Vitals:

Heart rate: 90 BPM 

Respiratory rate: 20 cycles per min 

Blood pressure: 130/90 mmHg 

Temperature: 98.6 °F 

SPO2: 98%

RBS: 118 mg/dl 

Systemic Examination: 

Central Nervous System: 

CNS:

Higher mental functions:

Oriented to time,place,person

Memory : recent, remote intact

Speech: normal, understandable

No delusions or hallucinations

Cranial nerves: 

1- not tested

2- binocular vision: normal

colour vision:normal

3,4,6- No restriction of movement of eye

5-normal( muscles of mastication+sensations of face) No jaw jerk

7-Normal, wrinking of forehead seen, able to blow up cheeks

8- Normal hearing

9,10,11,12-normal. Gag reflex is normal.

Motor examination:

Tone -normal

Power 

-4/5 in b/l lowerlimbs 

-4/5 in upper limbs

Reflexes :

Biceps:b/l:2+

Triceps:2+

Supinator 2+

Knee: not elicited (pain of the wounds)

Ankle: not elicited

Plantars: not elicted

Sensory examination:

 crude touch, pain ,temp, fine touch, joint position, proprioception are normal in all dermatomes in upper limbs.

Pain sensation seemed to be decreased in lower limbs, particularly the foot.

Cerebellum examination:

Able to do finger nose test.

No dysdiadokinesia 

No rebound tenderness 

Autonomic Nervous System:

No postural hypotension 

No bladder and bowel incontinence 

No sweating abnormalities

Meningeal signs:

No meningal signs like Brudzinski or Kernig sign were positive 

Gait: walk with limp due to wounds.

CVS: S1 S2+ no murmurs heard.

Respiratory system- Bilateral air entry+ ,normal vesicular breath sounds-heard. 

Abdominal: Soft, non tender, no distension, umbilicus is central and inverted,no scars, no sinuses, hernial orifices free.

Provisional diagnosis: 

Episode of altered sensorium secondary to hypoglycemia 

K/c/o Diabetes and hypertension 

 

Investigations:

Significant: Hemoglobin: 10.1 gm/dl 

MCV: 70 fl 

MCHC: 34.4 

Platelet count: 1.3 lakh 

Microcytic hypochromic anemia with relative thrombocytopenia.

No features suggestive of liver or kidney dysfunction.

ECG:

Management: 

SOAP notes:

Subjective: 

Episode of hypoglycemia 

No nausea, vomiting, fever 

Ulcer on left foot. Wound on right 5th toe 

Objective:

Pt is C\C\C 

Afebrile 

Bp: 130/90 mmHg 

HR: 90 BPM 

RR: 17 cycles/min 

GRBS: 118 mg/dl 

CNS: intact 

CVS: S1S2 + 

RS: BAE+ 

P/A: Soft, non- tender 

Assessment: K/c/o Diabetes and Hypertension, microcytic hypochromic anemia

Plan: 

On 8/1 : Inj 25% Dextrose i.v stat 

5% Dextrose at 50 ml/hour (increase or decrease according to GRBS)

Presently: Inj Piptaz 4.5 g i.v 

BP, GRBS monitoring 

Chest xray, CT brain and fundoscopy advised.

Question:

•What triggered his hypoglycemia? 

Age? Decreased physiological response to falling blood sugar. 

Hypoglycemia unawareness

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4499525/

https://pubmed.ncbi.nlm.nih.gov/30724638/

•What is the reason for his microcytic anemia?

•Is there a relation between anemia and diabetes?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6166192/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4658398/

These studies have shown that diabetes, associated with increase in Inflammatory mediators like IL-1 and IL-6, affects the production of RBC. 

(Can this be considered as Anemia of Chronic disease?) 

Diabetes can contribute to iron deficiency through reduced iron absorption, gastrointestinal bleeding and the complications like nephropathy.

 

 

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