T.shalini General medicine case presentation


General medicine case presentation short case


 CASE OF ALTERED SENSORIUM SECONDARY TO Diabetic ketoacidosis.



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 

Cheif complaint:

A 50 year male farmer ,manual labourer,brought to casualty with h/o altered sensorium since 1 day
H/o fever since 4 days.


HISTORY OF PRESENTING ILLNESS -

Patient was apparently asymptomatic 4 days ago,then he developed fever which is high grade,No diurnal variation, associated with chills.
No h/o cough and GE symptoms. 

Attenders tells h/o stoppage of OHA for 3days, h/o decreased intake of food as he has fever.

H/o altered sensorium since 1 day.
Irrelevant talk,not recognising attenders since this morning .
Able to move all four limbs,No h/o vomitings, head ache, seizures.
Took him to nalgonda hospital, TLC-13,000:POT-5.0:CREATININE:2.9
SHIFTED HERE FOR FURTHUR MANAGEMENT.
 
PAST HISTORY - 
H/o TB 2YRS back used ATT for 6 months.
Diagnosed as Type -2 Diabetes mellitus on OHA 1 YR back.
No H/O HTN,CVA,CAD,COVID-19.

PERSONAL HISTORY :

DIET - MIXED,
APPETITE -NORMAL ,
BOWEL MOVEMENT - REGULAR , 
BLADDER MOVEMENTS - REGULAR, ADDICTIONS-H/O SMOKING 30yrs ago(1 pack per day)- 
ALCOHOL-REGULAR INTAKE OF 180ML SINCE 30YRS,STOPPED SINCE 2YRS AFTER DIAGNOSIS OF TB.
RECENTLY ALCOHOL INTAKE ON JAN 15,2022.
FAMILY HISTORY:Non-significant.
TREATMENT HISTORY: on OHA SINCE 1YS.
ON ATT FOR 6MONTHS.

ON EXAMINATION -

PATIENT IS CONCIOUS , INCOHERENT NON COOPERATIVE
 NO ICTRUS 
 NO PALLOR
CLUBBING:present.
 NO CYANOSIS , NO LYMPHADENOPATHY, NO EDEMA

VITALS - 

TEMPERATURE - 97' F
PULSE RATE - 126BPM
BLOOD PRESSURE - 190/80 MM OF HG 
RESPIRATORY RATE - 28
SPO2 - 97 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : 
BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
DYSPNOEA PRESENT.

P/A - soft,non tenderness 
, no organomegaly


CNS: 
Pt is conscious, inorientation ,non cooperative 
HMF: couldnot be elicited.

Motor system:unable to move right LL against gravity.


Reflexes:
Biceps,triceps,supinator,knee,ankle:can't be elicited.

B/L PLANTAR EXTENSION PRESENT.
INVESTIGATIONs:








PROVISIONAL DIAGNOSIS:
CASE OF ALTERED SENSORIUM SECONDARY TO DKA.

TREATMENT :
1.IVF 2 UNITS NS IV_BOLUS/STAT.
AND THEN IVF NS@100ML/HR
2.INJ.HAI 6U/IV/STAT
3.INJ.HUMAN ACTRAPID 1ML(40U) 
4.INJ.THIAMINE 1AMP IN 100ML NS/IV/OD
5.INJ.OPTINEURON 1 AMP IN 100ML NS/IV
7.INJ.MONOCEF 2GM/IV/BD.










Comments

Post a Comment

Popular posts from this blog

Prefianl examination answers

Image
 1.Define Heart failure, etiology, and clinical features of heart failure? How do we diagnosis heart failure clinically, physical examination and various modalities used in diagnosis of heart failure. Write a brief note of treatment of heart failure 2.Define Cirrhosis of liver. Etiopathology of cirrhosis. Write a brief note on clinical features, diagnosis and treatment of cirrhosis of liver 3.Elabirate on clinical features and diagnostic modalities in diagnosis of renal calculi 4 . Etiology of pleural effusion diagnostic criteria of pleural effusion? 5.diagnosis and treatment of dengue fever? 6.clinical features and diagnosis of peptic ulcer disease 7.treatment of acutep pleo nephritis? 8 treatment of abdominal TB? 9.etiology and treatment of pnuemonia? 10.complications of dialysis ? 11.Ascitic fluid analysis 12..Proton pump inhibitors. 13.after load reducing agents in heart failure 14.treatment of urinary tract infection 15.diiferential diagnosis of fever with rash 16.insulin therapy
Read more

General medicine case presentation 5

Image
  This is an 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. A 15 years old male patient studying 9th class came to casuality with complaints of shortness of breath since 4 hours associated with acute chest pain since 4 hours. History of present illness: Patient was apparently asymptomatic 1 month back , patient complains of vomitings 2 to 3 episodes daily associated with food particles and not associated with blood. Patient gives history of fever 1 month back associated with chills which is relieved by using medication for 2 days. Incidentally he diagnosed raised urea 63 mg / dl and raised creatinine 8.3 mg/dl  went to Hyderabad with in one day urea has raised to 135 mg/dl and
Read more

Thakurshalini general Medicine case presentation 1

Image
It  is detail online elog to discuss  our patient de-identified health data shared after taking his / her guardian signed informed consent.  Here we are discuss about our individual patient problem through series of inputs from available global online community of an experts to solve patients clinical problem with collective correct best evidence based input. E blog also reflects my patient centered the learning portfolio and your valuable inputs on the comment box is welcome Date of admission: 4/8/2021 A 55 years old patient came to hospital with chief complaint of Decreased urine output since 3 days History of present illness: Patient was  apparently asymptomatic from past 1 year On date : 20/07/2021 he had sudden onset of shortness of breath (SOB) taken to hospital treated with Oxygen supply to treat SOB . Doctors told him that elevated creatinine levels in blood and adivised him to undergo dialysis On date : 26/7/2021  Patient is being prepared for Cvp line he suffered cardiac arre
Read more