65Y OLD MALE WITH ALTERED SENSORIUM
65Y OLD MALE WITH ALTERED SENSORIUM
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS 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
PATIENT CAME WITH CHEIFCOMPLANT OF ALTERED SENSORIUM SINCE 5AM (2/2/22), SOB(shortness of breath) GRADE IV SINCE TODAY MORNING.
HISTORY OF PRESENTING ILLNESS:
PATIENT WAS APPARENTLY ASYMPTOMATIC 20Y BACK, PATIENT WENTTO REGULAR CHECKUP AND CAME TO DIAGNOSE WITH DM-II.
18 YRS BACK HE HAD H/O TRAUMA ON LEFT LITTLE TOE AND DUE TO CELLULITIS ,LEFT LITTLE TOE HAS BEEN AMPUTATED.
SIX YRS BACK PATIENT AGAIN DEVELOPED LEFT LOWER LIMB CELLULITIS FOR WHICH FASCIOTOMY HAS BEEN DONE, SINCE THEN INSULIN HAS BEEN STARTED -MIXED INSULIN (30/70)35U -x-30U
LINAGLIPTIN 2.5MG/MF- 500MG AS DOCTORS MENTIONED RAISE OF CREATININE. (NO REPORTS AVAILABLE).
DAPAGLIFOZIN 10 MG WAS ADDED.
NO C/O CHEST PAIN, PALPITATIONS, ORTHOPNEA, POSTURNAL NOCTURNAL DYSPNEA.
C/O BURNING MICTURITION SINCE 2 DAYS.
H/O COVID-19 20 DAYS BACK
PAST HISTORY:
HE IS A KNOWN CASE OF DM SINCE 20 YRS.
NOT A KNOWN CASE OF HTN, BA, TB, CAD.
PERSONAL HISTORY:
DIET - MIXED,
APPETITE -NORMAL ,
BOWEL MOVEMENT - REGULAR , PASSED STOOLS YESTERDAY
BLADDER MOVEMENTS - REGULAR, ADDICTIONS(ALCOHOL AND SMOKING) - NO ADDICTIONS
NO KNOWN DRUG ALLERGIES
FAMILY HISTORY: NOT SIGNIFICANT
TREATMENT HISTORY:
Inj.25D IV/STAT
PATIENT IS CURRENTLY ON
T.CLINIDIPINE 10MG/PO/BD
ON EXAMINATION
PATIENT HAS ALTERED SENSORIUM
SIGNS OF PALLOR +, PEDAL EDEMA +
NO ICTERUS, CYANOSIS, CLUBBING OF FINGERS.
VITALS:
PR: 110 BPM
BP:180/80 MMHG
SPO2: 94% ON RA
GRBS: 33MG%-->225 MG%
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS HEARD
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS HEARD
PER ABDOMEN:
SHAPE OF THE ABDOMEN : OBESE
SOFT, NONTENDER, NO ORGANOMEGALY
CNS: PATIENT WAS DROWSY INITIALLY WITH SLURRED SPEECH
INVESTIGATIONS:
RTPCR : NEGATIVE
SEROLOGY:NEGATIVE
HEMOGRAM:
HB: 14.5
TLC: 9.600
N/L/E/M/B: 94/03/01/02/00
PCV: 42.1
MCV: 85.4
MCH: 29.4
MCHC:34.4
RBC:4.93
PT:1.30
RDW-CV :13.6
RDW-SD: 43.2
PS: NC/NC IMP: ABSOLUTE NEUTROPHILIA WITH MILD THROMBOCYTOPENIA
RFT:
BLOOD UREA : 46 MG/DL
SERUM CREATININE: 1.9
SERUM ELECTROLYTES:
Na+ : 138
K+: 5.7
Cl-: 103
LFT:
TB: 0.96
DB: 0.22
SGOT:49
SGOT:40
ALP:206
TP:6.3
ALBUMIN:3.8
A/G: 1.53
USG: IMP: B/L GRADE-1 RPD
ECG:
PROVISIONAL DIAGNOSIS:
HYPOGLYCEMIA SECONDARY TO OHA(oral hypoglycemic agents).
TREATMENT PLAN:
T.CLINIDIPINE 10MG/PO/BD
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