61 yr old male with loss of consciousness

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.



CHIEF COMPLAINTS

A 61yr old male came with chief complaints of brief loss of consciousness 3 days back. His GRBS on admission was 39mg/dl. After connecting on 25D he regained his consciousness.
H/o of vomiting 1 episode 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 3 yrs back Then he developed weakness for which he went to hospital & diagnosed with HTN & was started on Tab. TELMA- AM but was on irregular medication. Then he was fine till yesterday night. Then he had dinner & took HTN medication. Then he suddenly had brief loss of consciousness for 2 hrs. According to the patient he took 2 tablets that day after taking dinner

PAST HISTORY 

K/c/o HTN Since 3 yrs ( not on regular medication) 
Not a k/c/o DM , TB , EPILEPSY

PERSONAL HISTORY:

Moderately built and nourished.
Sleep normal.
Appetite is normal.
Bowel and bladder are regular.
He occassionally takes alcohol.

GENERAL EXAMINATION 

Patient is conscious, coherent and cooperative 

NO PALLOR , ICTERUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA

VITALS ON DAY OF ADMISSION 
PR- 62bpm
RR -18cpm
TEMP -98.3°F
BP- 110/70 mmHg

GRBS- 39mg%
SPo2-  98%on room air

SYSTEMIC EXAMINATION 

•CVS : S1 and S2 heart sounds heard .No murmurs and thrills
•RESPIRATORY SYSTEM : Bilateral air entry present                                             position of trachea - central
                                       Vesicular breath sounds heard
•CNS : NAD
•ABDOMEN : Soft and non tender
              No palpable masses
              Bowel sounds heard 
              No organomegaly
    
                   

       




He has cellulitis 2° to stasis eczema and ulcer over the right leg since 1 month for which swab was taken for culture and sensitivity and gram negative organisms were isolated.
                         

INVESTIGATIONS










ECG 

Vitals



Arterial And Venous Doppler 

                           


MRI brain
                            


Provisional Diagnosis: 
hypoglycemia secondary to OHA under evaluation.
 
Plan of treatment 
1. Stop OHA
2. IV fluids 25% dextrose infusion @ 10ml/ hr
3. Hourly GRBS monitoring
4.tab. telma 40mg po/od
5. Megaheal ointment for leg ulcer/tid
6. Bp/pr/temp monitoring 8th hourly .

Comments

Post a Comment

Popular posts from this blog

48 yr male with ascites, pedal edema since 2 months

Image
  This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 
Read more

Internship learning and procedures performed

Image
 INTERNSHIP LEARNING AND PROCEDURES PERFORMED This is prathyusha posted in medicine department from October 1st to 30 th November.   From 1st of oct to 15th October I was posted in peripherals Icu, nephro, ward In icu-  During my icu, amc duties  -I monitored vitals of patients every hourly -Took abg samples -put ryles tube for feeding -foleys catheterization - Done CPR in the icu - blood transfusion  In nephrology postings : Assisted in central line procedure and done suturing Monitored patients undergoing dialysis  Learnt about dialysis procedure In ward - took blood samples, monitored vitals  I was posted in psychiatry from 16th to 30th October In the OP saw cases of schizophrenia, Alcohol dependence syndrome, obsessive compulsive disorder.  Used to monitor patients in the De addiction center. One of the admission during my posting  Diagnosis - panic attack A 19 yr old male came to op with chief complaints of Increase in heart rate, hearing his own heart beat, fear of dying since 2
Read more

Evidence based date wise workflow logs.

 EVIDENCE BASED DATE WISE WORKFLOW LOGS  CASE 1 9/11/2023 PAJR link https://chat.whatsapp.com/D4GwL7frFWfAEuJbMXbNW8 Case report link  https://nvprathyusha100.blogspot.com/2023/11/31-yr-old-female-with-fever-since-5.html?m=1 A 31 year female came with chief complaints of fever since 5 months. Fever is high grade associated with chills and rigor , intermittent in nature, No diurnal variation It is associated with vomiting , food as content , no bilious , non projectile , no blood stained   H/o loss of appetite & weight loss  H/o burning sensation over the tongue and buccal mucosa since 3-4 months, insidious in onset, gradually progressive, aggravated when patient consumes spicy food and no relieving factors No h/o cough, cold No h/o chest pain , sob, orthopnea, pnd No h/o loose stools, constipation No h/o burning micturition, increased/decreased urine output. Not a k/c/o of HTN, DM, asthma, TB, epilepsy, CVA, CAD Vitals :  PR  : 76 bpm BP : 110/70 mmHg  RR : 20 cpm Temperature : 101
Read more