CASE PRESENTATION

PRESENTED BY
SNIGDHA P.N
 SUBJECTIVE EVIDENCE
NAME :X AGE: 77 YEARS SEX : F
IP NO:172763/16 DOA:5/2/16 DOD:10/2/16
REASON FOR ADMISSION

Sudden loss of conciousness from morning onwards.

Followed by shievering, rigiditity of limbs, clenching of jaws ;
lasted for 2-3min
 HISTORY OF PRESENT ILLNESS

• Unconcious from morning associated with shievering, rigidity of

limbs, clenching of jaws.
• Involuntary urination and defeccation.
• Had an episode of seizure after IV NS administration on 5/2/16.
• Bed sore present on 7/2/16

PAST MEDICAL HISTORY

• K/C/O Alzheimer's disease, HTN x 6months
• T2 DM x 1 year

PAST MEDICATION HISTORY

T.ADMENTA 10 mg OD (MEMANTINE)
T.AMLODAC 5mg BD (AMLODIPINE)
T.GLUCORED FORTE 500 +5 mg BD (METFORMIN + GLIBENCLAMIDE)
 OBJECTIVE EVIDENCE
VITAL SIGNS
DATE 5 6 7 8 9 10

BP 150/80 170/80 120/70 120/80 130/70 120/60

(mmHg)
PULSE(bpm) 102 102 102 80 65 64

SPO2 (%) 96 - 92 98 97 94
GRBS(mg/dl) 532 - 267 - 235 229
FBS(mg/dl) - - 182 218 110 192
I/O (ml) - 2250/1000 - 2250/1000 2600/1350 1000/800

GENERAL EXAMINATION
Pallor :+ ve
 DATE GENERAL EXAMINATION
5/2 PATIENT NOT CONCIOUS,NOT ORIENTED

6/2 UNCONCIOUS ,NOT RESPONDING TO STIMULI

7/2 PATIENT CONCIOUS

GCW SCORE :7
SYSTEMIC EXAMINATION
CNS :UL: Hypertonia
REFLEX R L
BICEPS ABSENT +

TRICEPS ABSENT +

KNEE + +
ANKLE + +
 LABORATORY EXAMINATIONS
PARAMETER 5/2 7/2
Hb 11.2 g% 10.2 g%

WBC 17,000/cmm 17,000/cmm

DC P 81, L 12,,M1 E4 P 83, L 14 ,M2, E1

ESR 35mm/hr 50mm/hr

PH (ECF) 4.1 2.0

S.Cr 1.9 mg/dl 1.8 mg/dl

S.ELECTROLYTES 5/2/16 8/2/16

S.Na 136mmol/l 132mmol/l

S.K 4.1mmol/l 2.9mmol/l

S.Cl 91mmol/l 98mmol/l

S.Ca 11 mg/dl -

Blood sugar value

FBS 182 mg/dl (7/2/16) 218 mg/dl (8/2/16)
RBS 469mg/dl (5/2/16)
GRBS 532 mg/dl (2pm) 288mg/dl (12am) (5/2/16)
 B.Urea :46mg/dl
S.Osmolarity : 331.7mosm/kg
pH :7.146
pCO2 :46.3mmHg (83-108mmHg)
CHCO3 :16 mmol/l (21-28 mmol/l)
CSO2 :96.6%

URE
Colour :pale yellow
Sugar :trace
RBC :2-4/HPF
PUS :2-4/HPF
Epi cells :1-3/HPF
 ASSESSMENT

HONK + DEMENTIA+DM
 GOALS OF TREATMENT

• Normalise the osmolality

• Replace fluid and electrolyte losses
• Normalise blood glucose

Other goals include prevention of:

• Arterial or venous thrombosis
• Other potential complications e.g. cerebral oedema/ central
pontine myelinolysis
• Foot ulceration
 TREATMENT

NO BRAND NAME GENERIC NAME DOSE 5 6 7 8 9 1

0
1 INJ.XONOCEF CEFTRIAXONE + 1.5g IV BD √ √ √ √ √ x
SULBACTUM
2 INJ.PANCARE PANTOPRAZOLE 40 mg BD √ √ √ √ √ x

3 T.AMLONG AMLODIPINE 5 mg BD x x √ √ √ √

4 INJ.R INSULIN INSULIN 8U SC stat x √ 6U x x x

REGULAR
5 T.ATEN ATENOLOL 0-0-1 50mg x x √ √ √ √

6 INJ.LUP INSULIN + R ISOPHANE 10U-15U- √ x x x x x

INSULIN INSULIN + REG 12U IV
INSULIN
7 INJ.LUP INSULIN + R ISOPHANE 8U-10U-6U x x √ x x x
INSULIN INSULIN + REG IV
INSULIN
8 INJ.MANNITOL MANNITOL 50ml stat √ x x x x x

9 T.ADMENTA MEMANTINE 10mg HS x x x x x √

10 T.PANCARE 40 PANTOPRAZOLE 40 mg BD x x x x x √
11 INJ.INSULIN NPH +INSULIN 16U-0-10U x x x √ x √
30/70 REGULAR

DISCHARGE MEDICATION

T.AMLONG (AMLODIPINE) 5mg BD

T.PANCARE 40 (PANTOPRAZOLE ) 40 mg BD R/A 1 WEEK
T.ADMENTA (MEMANTINE ) 10 mg 0-0-1
INJ.INSULIN 30/70 (NPH +INSULIN REGULAR)
15U-0-10U
 MEDICATION ERROR
• No drug was prescribed for DEMENTIA initially
• T.AMLODIPINE was prescribed when patient was
unconcious.
• No treatment was given when potassium levels fall below
3mmol/l,
30 mmol of K+ diluted in 1 litre NS or ½ NS should be given over
1 h until K+ returns normal.
• Biphasic insulin can‘t be given as infusion but is prescribed .
• No therapy is given for bedsore .
 DRUG INTERACTION
Moderate Interaction

AMLODIPINE ATENOLOL
The concomitant use of these two drugs may increase
antihypertensive effects. So monitor BP closely.
 ADVERSE DRUG REACTIONS
• OBSERVED ADR
ATENOLOL induced postural hypotension.

DRUG EXPECTED ADRS

CEFTRIAXONE DIARRHOEA,

AMLODIPINE PALPITATION,EDEMA,HEADACHE

ATENOLOL HYPOTENSION,BRADYCARDIA,EDEMA

MEMANTINE GIDDINESS,HYPERTENSION,SYNCOPE
 MONITORING PARAMETERS

DRUG MONITORING PARAMETERS

AMLODIPINE BP,BODY WEIGHT
ATENOLOL BP,RADIAL PULSE,RESPIRATION
MEMANTINE Hb, CNS FUNCTION
INSULIN BLOOD SUGAR,S.POTASSIUM
 PATIENT COUNSELLING
DRUG RELATED
• Patient should be adviced not to stop the drug abruptly.
• Report if palpitation,facial puffiness e.t.c occur
• Take insulin regularly,donot skip meals.
• Sugar candy may help to overcome hypoglycemic symptoms.
• DISEASE RELATED
• Take care while walking,avoid fall.
• Water bed can be used for bed sore.
• If patients are too confused or sleepy immediately seek
medical attention.
• Examine feet each day since high risk for development of
pressure ulcers.
 PHARMACOECONOMIC EVALUATION

DRUG NAME COST (RS) ALTERNATIVE BRAND

WITH COST

T.AMLONG 49 Rs /10 tab T.AMLODAC 12 Rs /10 tab

T.ATENOLOL 80 Ps /10 tab T.AMLOKIND 10 Rs /10 tab