Pratama Wicaksana
Narissa Dewi Maulany
Mona Jamtani
King Hans
Nurul Larasati
Margaretha Gunawan
Supervisors: Prof. Sarwono & Prof
CASE DISCUSSION:
DECREASE CONSCIOUSNESS
Case Illustration
Patient Identity
 Name: Mr. R
 Gender: Male
 Age: 47 years old
 Religion: Islam
 Address: Jl. Mardani Raya Gg. T/41 RT 003/005, Johar
Baru, Jakarta Pusat
 Medical record number: 345-94-82
 Date of admission: December 27th 2010.
Chief Complaint
 Decrease of consciousness since 14 hours
prior to hospital admission.
patient started to talk
unaccordingly, not
being able to
communicated with,
and looked drowsy as
if he was going on a
sleep, then pt. was
brought to the
hospital.
There was a complain
of headache and
nausea, patient
vomited 2 times
which were consisted
of food and water.
There was no problem
with voiding, and the
last defecation was 4
days ago.
Other Complaints
general weaknesses,
pt can’t walk thus
needed help to
mobilize. The
weaknesses was felt
at the same intensity
on the four
extremities. There
was also decrease of
appetite (pt only drink
and eat a bit of
porridge), no mouth
deviation and no
slurred speech was
noticed. Pt also
complained of
shortness of breath,
on exertion and at
rest. There was no
chest pain.
14H PTHA
3days PTHA
History of Present Illness
Symptoms of
frequent eating,
urinating, and
sleepiness has been
noticed by his wife
daily, but there was no
numbness, tingling
sensation, nor
persistent wound
complained by the
patient.
Past history of illness
 History of type II DM since 5 years ago: does
not take medicine regularly and does not
know the type of drugs
 Hypertension since 3 years ago: was on
captopril-taken regularly and regular visit to
the physician
 no asthma, no history of lung disease or Anti
TB drugs, no history of previous stroke, and
no history of drug allergy
 Family history of illness
 There was no familial history of hypertension,
asthma, heart disease, lung disease, and allergy
 Social and working history
 Patient smoked for 30 years, but has stopped
smoking since 4 months ago
Physical Examination
on admission to the Emergency Department
(27/12/2010)
Physical Examination
Vital signs
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Consciousness: spoor, GCS: E2M4V2 = 8
General condition: look severely ill
Blood pressure: 80/60 mmHg
Pulse: 110x/minute, weak
Temperature: 36.70C (axilla temperature)
Respiratory rate: 32x/minute, fast and deep
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Skin : Not pale, not cyanotic, not icteric
Head : Normochepal.
Hair : Black, not easily pulled
Eyes : Pale conjunctiva (-/-), icteric sclera (/-), Round pupil, isochor, diameter 3mm,
direct light reflex +/+, indirect light reflex
+/+.
Ears : Auricula N/N, tymphanic membrane
intact, no cerumen.
Nose : No deviation of septum
Throat
: Tonsil T1/T1 calm,
pharyngeal arch symmetrical, uvula in the
middle, pharynx not hyperemic.
Teeth and mouth: no caries, no oral thrust
Neck : Trachea in the middle, JVP 5-2
cmH2O, lymph node was not palpable, no
mass, Meningeal signs: neck stiffness (-),
Laseque >70o />70o, Kernig >135o/>135
Physical Examination
Lungs
 Inspection : symmetrical,
static and dynamic.
 Palpation
: fremitus are same
in both lungs
 Percussion : sonor on all lung
fields.
 Auscultation : Vesicular (+/+), no
rhales, no wheezing.
 Back
:
symmetric in static and dynamic
movement, sonor, vesicular, no
rhales and no wheezing
Heart
 Inspection : Ictus cordis is not
visible
 Palpation
: ictus cordis is
palpable at ICS 5, on the mid
clavicular line
 Percussion : right heart border
at linea sternalis dextra, upper
heart border at ICS III linea para
sternalis sinistra, and left heart
border at 3 fingers lateral from
linea mid clavicularis sinistra.
 Auscultation : Normal first and
second heart sound, no murmur,
no gallop.
Physical Examination
Abdomen
 Inspection : flat, supple.
 Palpation
: hepar and spleen
is not palpable
 Percussion : tymphanic (+)
 Auscultation : Bowel sound (+),
normal.
Genitals: not performed.
Rectal touché: not performed.
 Extremities: warm, CRT >2”, no
edema,
 Motoric reflex: no hemiparesis,
physiological reflex: +2/+2,
+2/+2
pathological reflex: none
 Sensoric reflex: can’t be
assessed
 Autonomic reflex: no urinary or
defecation incontinence
 Lymph nodes: There was no
palpable lymph node
enlargement
Summary

Patient a gentleman aged 47yo came with chief complaint of decrease
consciousness since 14hours prior to hospital admission. Since 3 days
before hospital admission, patient has been complaining of general
weaknesses which was felt at the same intensity on the four extremities.
There was also decrease of appetite. Pt also complained of shortness of
breath, on exertion and at rest. 14 hours prior to hospital admission,
patient started to talk inaccordingly, not being able to communicated
with, and looked drowsy as if he was going on a sleep, then pt. was
brought to the hospital. There was a complain of headache and nausea,
patient vomitted 2 times which were consisted of food and water.
Symptoms of frequent eating, urinating, and sleepiness was noticed by
his wife. Patient has history of type II DM since 5 years ago: does not
take medicine regularly and does not know the type of drugs,
hypertension since 3 years ago: was on captopril-taken regularly and
regular visit to the physician. Patient smoked for 30 years, but has
stopped smoking since 4 months ago. Laboratory results showed
leukocytosis, increase plasma ureum and creatinine, very high level of
blood glucose, hypokalemia, metabolic acidosis, and positive plasma
ketone 3-hydroxybutyrate.
Problem list:
 Decrease of consciousness ec hypovolemic shock ec
Diabetic Ketoacidosis
 Diabetic Ketoacidosis on DM Type II with history of
uncontrolled blood glucose
 Dyspepsia with difficulty of intake
Plan
 Diagnosis plan:
 ECG, chest x-ray
 CBC, diff count, electrolytes, arterial blood gas analysis,
keton 3Hb, blood chemistry, urinalysis, Brain CT
Laboratory Examination
Peripheral blood test (28/12/2010):
Result
Normal range
Haemoglobin
12.6 (↓)
12-14
g/dL
Haematocryte
37
40-46
%
Leukocyte
14.300 (↑)
5.000-10.000
/uL
Thrombocyte
167.000
150.000-400.000
/uL
MCV
85
82-92
fL
MCH
29
27-31
pq
MCHC
34
32-36
10^3/uL
Routine hematology
Blood chemistry
Blood Ureum
179 (↑)
<50
Mg/dL
Blood Creatinine
1.7 (↑)
0,6-1,2
Mg/dL
Laboratory Examination
Peripheral blood test (28/12/2010):
Electrolytes
Natrium
131
135-147
Kalium
6.2(↑)
3.5-5.5
Chloride
106
100-106
Arterial Blood Gas Analysis
pH
7.091()
7.320-7.450
PCO2
19.7()
35-45
PO2
154(↑)
75-100
SO2
98.6
HCO3
6.1
21-25
Keton 3Hb
2.8
<0.5
Treatment plan:
 O2 2 litre/ minute per nasal cannule
 Loading NaCl 0.9%  up to 3000cc, MAP target >65
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Followed by NaCl 0.9% in 8hour
Haemacel in 12hour
Insulin: 10IU  IV followed by 5IU/hour drip
HCO3 50meq/6H
Folley Catheter: Fluid Balance in 24H
Omeprazole 1x40mg IV
Prognosis:
 Quo ad vitam: Dubia ad bonam
 Quo ad functionam: dubia ad bonam
 Quo ad sanactionam: Dubia ad malam
CASE DISCUSSION
Decreased consciousness et
causa Hypovolemic Shock et
causa Diabetic Ketoacidosis
Decreased consciousness et
causa hypovolemic shock
Decreased
conciousness
GCS 8
Hemiparesis (-)
Shock
80/60 mmHg,
110x/minute
inadequate
volume ,
32x/minute
,deep, (kussmaul)
T: 36,7OC
Fluid resuscitation
good response
shock hypovolemia,
suspect metabolic
condition.
Fever (-), focus of
infection (-) sepsis
excluded.
hemorrhage (-),
dehydration, diarrhea (-)
 excluded
History of heart disease
(-) excluded
Diabetes Mellitus History
History of diabetes
mellitus type 2, didn’t
take medication
regularly
Recent history: general
weakness, anorexia,
lethargy, and decreased
of consciousness
Polyuria(+),
polydipsy (+),
polyfagi (+), weight
loss (+)
Suspect
Diabetic
Ketoacidosis
Planing: blood
glucose test,
urinalysis, blood
gas analysis,
and ketone
Working Diagnosis
Glycemia > 500mg/dl,
ketone 3HB 2.8 mg ↑.
blood PH is 7,09↓, PCO2
19.7↓, PO2 154 ↓, HCO3
6,6↓,
Decreased
consciousness et causa
Hypovolemic Shock et
causa Diabetic
Ketoacidosis
Pathophysiology DKA
Glukagon↑
Insulin↓↓
Fat tissue
lipolysis↑↑
Liver
ketogenesi
s
Acidosis
(ketosis)
Liver
glukoneogenesi
s
Peripheral
tissue
glucose
consumption
↓↓
osmolarity↑↑
Hypovolemic Shock in
Ketoacidosis DM
hyperglycemia and
ketone  vascular
osmolarity ↑↑
polyuria, electrolyte
losses, dehydration, and
eventually hypovolemia 
shock
(Osmotic )
Diuresis ↑↑
Metabolic Acidosis
Lipolysis & ketogenesis
Ion exchange across cell
membranes  intracellular
acidosis  alter abnormal
celular metabolism
Metabolic acidosis
ketone 3HB &
acetoacetate in
circulation ↑
Unable to buffer PH↓↓
Encephalopathy Metabolic
acidity↑↑
increase Intracranial
Pressure
Decrease of
consciousness
PCO2↓↓
Vasodilatation of
vascular brain
Leakage of
vascular volume
Management of Fluid
Resucitation
 fluid resuscitation  3000cc in 3hour to reach
the MAP of >65 (in 3h BP of 90/65 was
achieved fluid replacement was then
continued for another 1000cc in 4 hours 
reaching BP of 120/80 (MAP:120), 
continue with maintenance fluid
Management of Hyperglicemia
 Insulin IV  initially 10IU for the very high
blood glucose concentration (>500g/dL) 
then followed by continuous IV 5IU/hour. In
7hours, blood glucose level of 178g/dL was
achieved patient consciousness developed
to delirium.
Management of abdominal
dyscomfort
 abdominal discomfort & prevent recurrent
vomit  omeprazole 2x40mg IV was given.
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Warrel, et al. Oxford Textbook of Medicine. 4th ed.
USA: Oxford Press; 2003. P: 220-225
Rucker, Donald. Diabetic ketoacidosis. Emergency
medicine. www.emedicine.medscape.com. 2009.
Sudoyo AW, Setiyohadi B, Alwi I et al. Buku Ajar
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