61yr Female with Altered Sensorium
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.
I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan
CONSENT AND DEIDENTIFICATION :
PRESENTING COMPLAINTS:
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 10yrs back and then she developed dizziness, numbness and tingling sensation, burning sensation of hands and foot especially during night and was diagnosed with Diabetes Mellitus for which she is on medication.
8months back she developed neck pain, headache, leg pain, body pains and was diagnosed with Hypertension for which she is on medication(not using regularly)
10 days back she developed fever, vomitings and weakness for which she went to local Area hospital and got treatment.
From 2 days ago she was taking DM medication(OHA) without intake of food and at last night she suddenly developed altered sensorium and was brought to hospital.
HISTORY OF PAST ILLNESS:
Known case of DM since 10yrs
Known case of HTN since 8months
Not K/C/O TB, Epilepsy, Asthma, CAD
PERSONAL HISTORY:
Diet- Mixed
Appetite- Decreased since 5days
Sleep- Inadequate
Bowel and bladder movements- Irregular
No Addictions
No Allergies
FAMILY HISTORY:
No significant family history.
GENERAL EXAMINATION:
Patient is conscious, coherent, co-operative
Pallor- present
No Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema.
VITALS:
BP- 130/90mmhg
PR- 82bpm
RR- 16cpm
SpO2- 97% at room air
GRBS- 39mg/dl @ admission
Temperature- 98.8F
Per Abdomen:
Upper limb Lower limb
Right Left Right Left
Tone: Normal Normal Normal Normal
Power: 5/5 5/5 5/5 5/5
Reflexes: Right Left
Biceps + +
Triceps + +
Supinator + +
Knee + +
Ankle + +
Plantar Flexion Flexion
INVESTIGATIONS:
2d-echo:
CHEST X-RAY:
ECG:
PROVISIONAL DIAGNOSIS:
Recurrent Hypoglycaemia (Oral Hypoglycaemic Agents induced);
Pre-Renal(non Oliguric) AKI;
Diabetes Mellitus-II with End organ damage (Retinopathy, Neuropathy- Glove and stocking + Gastroparesis, Nephropathy)
TREATMENT:
Comments
Post a Comment