65 YEAR OLD male presented UNCONSCIOUS

 ELOG

20th june 2023

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.



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




A 65 year old male, resident of nalgonda, farmer by occupation presented to the casualty with

CHIEF COMPLAINTS --
1. Loss of consciousness, not waking up from the bed
2. Weakness in the body since 20 days
3. Loss of speech since 20 days

HISTORY OF PRESENT ILLNESS

The patient was apparently symptomatic 4 YEARS back when one day he collapsed beside the bed at 2:00 a.m. in the morning when he woke up to use the washroom
He complained of feeling giddiness which caused the fall. He was put back in the bed by his wife.
Next day morning when he woke up he fell down the bed again due to malaise and weakness in his Limbs, he was conscious and responding well

Upon consulting an RMP he was given glucose and 2 injections
Futher they consulted another doctor, where he was diagnosed with diabetes mellitus and hypertension and was given medications for the same

He has been frequently visiting the same hospital and getting medications once every week or once every 2 weeks

 3 YEARS back he was admitted in a hospital due to high fever, diagnosed to be dengue as stated by his wife
The patient was apparantly warned about his kidney being damaged during his frequent visits, which he didn't share with his wife.

30 days back, the patient started scolding and screaming at his wife at 4 am in the morning, but his speech was not clear
He was taken to a nearby hospital where they were told that his blood pressure is high and blood glucose level is low
He was treated and sent back home

7 days back he has visited our hospital with complaints of not being able to walk properly since 3 days, and he was asked to come the next day

The next morning he was unconscious and didn't wake up from his sleep, and was brought to the hospital in an ambulance


HISTORY OF PAST ILLNESS

Umbilical hernia since birth/childhood?

He has complained of having back pain since 3 years for which he occasionally took medicines

 He had constipation since 6 days before being admitted at our hospital

DAILY ROUTINE
 
Before illness:

Wakes up at 5am
Roams around the village
Reaches the home at 7 
Has tea
Goes for work, daily labour work or farm
Comes back at 10 to have breakfast 
Goes back for work and comes at 1pm for lunch
Goes back to work at 2
Comes back in evening or night at flexible times 
Has dinner at 8 and sleeps

After illness;

Wakes up at 6am 
Has tea and breakfast 
Takes rest
Has lunch with wife
Sleeps for a while
Washes his clothes at 3pm 
Shifts the wooden sticks from outside the house 
And further has dinner and sleeps


PERSONAL HISTORY 

sleep normal

Appetite lost since 20days (does not eat vankay,gongura,potato)

Bowel movements- occured twice since the 20 days before he came here

Bladder normal

Allergy nill

Addictions nill, occasionally drinks alcohol 


FAMILY HISTORY 

 Brother has history of Diabetes 

TREATMENT HISTORY 

Has been on oral hypoglycemic drugs and antihypertensives since 4 years



GENERAL EXAMINATION 

Patient was concious coherent oriented to time and place
Moderately built and moderately nourished

Pallor present 
Icterus NO
Cyanosis NO
Kolionychia NO
Lymphadenopathy NO
Edema present 









SYSTEMIC EXAMINATION 

Cvs 
    s1 s2 heard
    No murmurs heard

Respiratory examination:
  Scar on chest due to trauma, keloid?
  Trachea i middle, vesicular breath sounds heard 
   

Abdominal examination:
  Umbilical hernia present, flanks are full
  Shifting dullness positive
  Bowel sound heard

CNS



INVESTIGATIONS 










TREATMENT 


15.6.23

FLUID RESTRICTION <2 LTS /DAY
2.SALT RESTRICTION <2 GMS/DAY
3.Inj. CLINDAMYCIN 60mg iv/TID
4.Inj. PIPTAZ 2.25gm iv/TID
5. Inj.HUMAN ACTRAPID INSULIN
6.Inj. LASIKS 40mg iv/BD
7.Tab. NOCARDIA 20 mg PO/TID
8.Tab.ARKAMIN O.1 mg PO/TID
9.Tab. OROFER XT PO/OD
10.Tab. SHELCAL CT 500 mg PO /BD
11.Tab. NODOSIS 500mg PO/BD
12.Cap. BIO-D3 Weekly once / PO
13.Syp. CREMAFFIN PLUS 15ml PO/SOS
14.GRBS every 4th hrly
15.Monster Vitals every 2 hrly



16.6.23

FLUID RESTRICTION <2 LTS /DAY
2.SALT RESTRICTION <2 GMS/DAY
3.Inj. CLINDAMYCIN 60mg iv/TID
4.Inj. PIPTAZ 2.25gm iv/TID
5. Inj.HUMAN ACTRAPID INSULIN
6.Inj. LASIKS 40mg iv/BD
7.Tab. NOCARDIA 20 mg PO/TID
8.Tab.ARKAMIN O.1 mg PO/TID
9.Tab. OROFER XT PO/OD
10.Tab. SHELCAL CT 500 mg PO /BD
11.Tab. NODOSIS 500mg PO/BD
12.Cap. BIO-D3 Weekly once / PO
13.Syp. CREMAFFIN PLUS 15ml PO/SOS
14.GRBS every 4th hrly
15.Monster Vitals every 2 hrly


17.6.23

FLUID RESTRICTION <2 LTS /DAY
2.SALT RESTRICTION <2 GMS/DAY
3.Inj. CLINDAMYCIN 60mg iv/TID
4.Inj. PIPTAZ 2.25gm iv/TID
5. Inj.HUMAN ACTRAPID INSULIN
6.Inj. LASIKS 40mg iv/BD
7.Tab. NOCARDIA 20 mg PO/TID
8.Tab.ARKAMIN O.1 mg PO/TID
9.Tab. OROFER XT PO/OD
10.Tab. SHELCAL CT 500 mg PO /BD
11.Tab. NODOSIS 500mg PO/BD
12.Cap. BIO-D3 Weekly once / PO
13.Syp. CREMAFFIN PLUS 15ml PO/SOS
14.GRBS every 4th hrly
15.Monster Vitals every 2 hrly


18.6.23

FLUID RESTRICTION <2 LTS /DAY
2.SALT RESTRICTION <2 GMS/DAY
3.Inj. CLINDAMYCIN 60mg iv/TID
4.Inj. PIPTAZ 2.25gm iv/TID
5. Inj.HUMAN ACTRAPID INSULIN
6.Inj. LASIKS 40mg iv/BD
7.Tab. NOCARDIA 20 mg PO/TID
8.Tab.ARKAMIN O.1 mg PO/TID
9.Tab. OROFER XT PO/OD
10.Tab. SHELCAL CT 500 mg PO /BD
11.Tab. NODOSIS 500mg PO/BD
12.Cap. BIO-D3 Weekly once / PO
13.Syp. CREMAFFIN PLUS 15ml PO/SOS
14.GRBS every 4th hrly
15.Monster Vitals every 2 hrly


19.6 23

FLUID RESTRICTION <2 LTS /DAY
2.SALT RESTRICTION <2 GMS/DAY
3.Inj. CLINDAMYCIN 60mg iv/TID
4.Inj. PIPTAZ 2.25gm iv/TID
5. Inj.HUMAN ACTRAPID INSULIN
6.Inj. LASIKS 40mg iv/BD
7.Tab. NOCARDIA 20 mg PO/TID
8.Tab.ARKAMIN O.1 mg PO/TID
9.Tab. OROFER XT PO/OD
10.Tab. SHELCAL CT 500 mg PO /BD
11.Tab. NODOSIS 500mg PO/BD
12.Cap. BIO-D3 Weekly once / PO
13.Syp. CREMAFFIN PLUS 15ml PO/SOS
14.GRBS every 4th hrly
15.Monster Vitals every 2 hrly


Comments

Post a Comment

Popular posts from this blog

OSCE QUESTIONS prefinals

Image
 OSCE points and questions common for all that all must be prepared to answer in their patients: <> What bothers your patient the most and what are his active concerns?  List the problems in your patient in order of patient priorities and requirements  1, the patient’s main concern is about not being able to eat her food to suffice her appetite and perform the house chores 2, She is not able to even visit the washroom without help and this has also affected her mentally as she didn’t like that she is being dependant on someone  3, SOB even on rest lead to disturbed sleep <>Sequence of events : What was your patient's hourly workflow before the illness and how did it change after?  BEFORE ILLNESS She used to wake up at 6 AM and 10 to her house or activities which included the washing the dishes and cooking breakfast and at 10 AM. She used to have a breakfast and breakfast used to consist of rice and curry. After that finish used to clean the household and catch up on tal
Read more

Long case 2 (1/12/2023)

Image
 mvineelarollno90 [Case Based OSCE ]65 Y female with C/O fever since 4 days, SOB since 2 days,pedal edema since 2 days November 20, 2023  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. 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 tre
Read more

Long case 1 (1/12/2023)

Image
 November 29, 2023 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 A 60 year old female has come to the opd with CHIEF COMPLAINTS of  1. shortness of breath since 2 months 2. Chest pain 10 days back HISTORY OF PRESENTING ILLNESS Patient was apparently asymp
Read more