Delirium Case

Presentation
Wong Chui Yee
Patient Demographics
Mdm P

72 years old, Malay,

Housewife

Underlying T2DM, Hypertension, Advanced CKD

Admitted on 10th July 2017

Presenting Complaint
Reduced responsiveness for 1/7
Noted by daughter at home to not respond to call

Appeared lethargic

Cold peripheries

Reduced oral intake for 1/52

Poor appetite for 1/52

Not associated with nausea, vomiting, abdomen pain

Still given usual insulin dose despite poor oral intake [last dose 26u
Insulatard before bed]
Presenting Complaint cont.
Patient denies having hypoglycemic ssx eg. dizziness, tremors, cold
sweats, anxiety. Only felt sleepy and lethargic.

Upon arrival in ED, GM was undetectable. Given D50% 50cc stat and IVD
D10%, GM after that was 4.7.

Systems review:
CVS: no chest pain, exertional dyspnea, orthopnea, PND, intermittent
claudication, palpitations
Respi: no URTI ssx

GI: no fever, no changes in bowel habits

Past Medical History
T2DM
Diagnosed 6 years ago, under regular follow up at KK
Hypertension
Chronic kidney disease approaching ESRF
Not on RRT

? Past hospitalisations
No previous surgeries

No known drug allergies

Drug History
S/C Insulatard 26u ON

S/C Actrapid tds

T. Simvastatin 40mg ON

T. CaCO3 500mg tds

T. Amlodipine 10mg OD

T. Diltiazem HCl 90mg tds

T. Aspirin 75mg OD

T. Ferrous Fumarate/Bco/Vit C/Folic acid OD

T. Bisoprolol 2.5mg OD

T. Frusemide 40mg tds

Social History
Non smoker

Does not consume alcohol

Lives with daughter and grandchildren

Poor knowledge about medications everything is taken care of

by daughter and grandchildren
Patient is not keen to go on long term RRT.

Family is also not keen for patient to go on long term RRT as

patients husband is also ill unable to take care of both sides.
 Physical Examination
Vitals
BP 121/54 mmHg

HR 76/min

T 37C

SpO2 99% under RA

Drowsy but easily aroused, lethargic looking, disorientated to time, orientated to
place and person

Normal body built, lichenification over UL and back, no AVF on both hands

Face sallow complex, conjunctival pallor, no scleral icterus

CVS S1S2 no murmur

Lungs minimal bibasal crepts

Abdomen soft, non tender, no palpable masses

LL pitting edema up to shin, multiple scratch marks

MMSE
2
2

2
1
2

0
0
1

16
Alert
Confusion Assessment Method (CAM)
Investigations
Bloods
FBC Hb 6.9 / MCV 84.8 / MCH 28.2 / WCC 17.6 / PC 324

RP BU 41.2 / Na 140 / K 4.10 / Cl 101.6 / Creat 1192

CE CK 136 / AST 26.4 / LDH 641

ABG pH 7.228 / pCO2 20.7 / HCO3 10.8

CXR Lung fields clear, cardiomegaly

ECG T inversion at I, II, V5, V6

Diagnosis
1. Hypoglycemia secondary to insulin overdose

2. Advanced CKD approaching ESRF

3. Delirium secondary to 1 & 2

Management Plan
To discuss with family re: long term RRT and immediate RRT if
needed
KIV hemodialysis if acidotic

IV omeprazole 40mg OD

GM hourly

Encourage orally
Progress
After multiple discussions with patient and family, both sides are still
not keen for long term RRT.
1x HD was done on 13th July 2017 via femoral catheter.

Patients cognition and general condition improved post HD.

Discharged on 14th July 2017.