Skip to main content

General Medicine case study


2

Ch Janani 

Roll no .29

Below is an elog describing patient centered data approach and discussion regarding patient deidentified health data.

CHIEF COMPLAINTS

A 75 year male patient from chotuppal came to causality with chief complaints of unresponsiveness and unable to speak. 

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 4 days back. Then skipped his breakfast and his medicine ( voglibose, metformin, glimiperide) due to other works. Then he became unresponsiveness on 6/06/22 morning. Then was taken to hospital.

 HISTORY OF PAST ILLNESS

He was apparently asymptotic 6 years back. Then he went to hospital due to decreased responsiveness and was diagnosed as DM -II.

He is n/k/c/o HTN, CAD , Asthma, epilepsy, TB

PERSONAL HISTORY

Married

Diet: mixed

Appetite: normal

Bowel movements: normal

Bladder movements: normal

Alcoholic ( drinks intermittently)

Non smoker

FAMILY HISTORY

Not a k/c/o asthma , TB, epilepsy, diabetes, HTN, CAD

GENERAL EXAMINATION

Moderately built, moderately nourished and 

No pallor 

No cyanosis

No icterus

No clubbing

No edema

No lymphadenopathy

SYSTEMIC EXAMINATION

CVS : 

No thrills 

no murmurs

S1 S2 present

RESPIRATORY SYSTEM:

No dyspnoea

No wheezing

Position of trachea is central

Breath sounds is vesicular

ABDOMEN:

Shape of abdomen: scaphoid

No tenderness

No palpable mass

Hernial orifices are normal

No free fluid 

No bruits

Liver: not palpable

Spleen: not palpable

Bowel sounds : yes

CNS :

No stiffness

No kernigs sign

Cranial nerves , motor system , sensory system, Glasgow scale are normal

PROVISIONAL DIAGNOSIS:

Altered sensorium secondary to OHA induced hypoglycaemia.

CKD (diabetic nephropathy)

INVESTIGATIONS ORDERED :

On 7/06/22




 




On 8/06/22:


TREATMENT:

IV fluids DNS @50 ml/hr continuous infusion

Inj Optineuron 1 amp in 100 ml/NS/ IV / OD

Inj 25% dextrose IV/sos if GRBS < 70mg/dp

TAB Pantop 40 mg/ Po/ Od

GRBS monitoring help

Inform of if GRBS < 70 mg/dl

Strict I /O charting













 

 

Comments

Post a Comment

Popular posts from this blog

general medicine practicals

Image
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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 Chief complaints : b/l pain in lower limbs upto knees since 20 days  B/l swelling in the leg since 20 days  HOPi : Pt was appently asymptomatic 3 yrs back then he developed sudden pain in right sid...
Read more

General medicine

Image
Ch Janani Roll no. 29 A female patient aged 74 yrs  came to the OPD with chief complaints of fever  ,shortness of breath ,and she had altered sensorium. Chief complaints Fever ( 7 days) Shortness of breath(4 days ) Altered sensorium ( 2-3 days) History of present illness Patient was apparently asymptomatic 10 days back and She was admitted to hospital by her family due to loss of consciousness,fever,loss of speech and altered sensorium. History of past illness N/k/c/o diabetes mellitus,CAD and CVA hypertension,TB, epilepsy,no previous surgeries. She is a known case of asthma using inhalers ( duration not known) Personal history She is married Diet : mixed Bowel and bladder movements: normal  Appetite: normal No allergies No addictions Drug history: used pain killers for pain and swelling of lower limbs General examination  Palor No cyanosis No icterus No clubbing of fingers Pedal edema present ( pitting type )  Moderately built No Lymphadenopathy Vitals   T...
Read more

case 1

Ch Janani Roll no .29 A 28 yr female patient resident of Surat came to OPD with chief complaints of left side flank pain, shortness of breath and dysuria. Cheif complaint Left side flank pain Dyspnoea One episode of hematuria and dysuria History of present illness Patient was apparently asymptomatic 15yrs ( i.e in 2007 ) she had complaints of loss of weight and appetite for which she was diagnosed as pulmonary tuberculosis and on started on anti tubercular therapy .But she discontinued the treatment and she was kept of 8 months ATT.and in 2020 she developed low back ache for which she was diagnosed as renal calculi.now she came to our hospital with c/o left flank pain , dyspnoea grade 2,one episode of hematuria. History of past illness Hematuria,k/c/o tuberculosis in childhood No h/o of diabetes , hypertension, epilepsy and no previous surgeries. Personal history Married Appetite:normal  Diet : mixed  Bowels: irregular  Micturition:normal  Non alcoholic non smoker an...
Read more