Hi, I am p.samhitha 5th Sem Medical Student.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

A 63Y/M with loss of consciousness 6 hours ago 

Hi, I am p.samhitha 5th Sem Medical Student.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 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 a diagnosis and treatment plan.

Patient came to casuality with the history of loss of consciousness at 3 pm today . 

HISTORY OF PRESENTING ILLNESS :- 

Patient was approved asymptomatic till yesterday evening 

then her attenders  noticed she was in altered sensorium with intact consciousness by  the time they returned from work and today

afternoon 3pm while eating patient lost consciousness( for 30 min) 

And was taken to the hospital and GRBS Was 56 ( hypoglycaemic) and was started on 25 % D 

And patient regained and intact sensorium since then and was brought here for further management.

C/O one episode of vomiting 

No complaints of fever ; vomitings ; loose stools ; pain abdomen 

Burning micturition; seizures 

PAST HISTORY:- 

Known case of DM Since 6 months ( on unknown medication) 

Known case of ? CKD since 20 yrs ( not on any medication)

Not a known case of HTN; CVA ; Thyroid ; TB ; asthma epilepsy .

PERSONAL HISTORY:-

Diet - mixed 

Appetite- normal

Sleep - adequate 

Micturition:- incontinence since 2 months 

Allergic history:- No history of any kind of allergies for food/drugs

Family history:- no significant family history 

GENERAL EXAMINATION:- 

PATIENT IS CONSCIOUS COHERENT AND CO OPERATIVE 

NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ; LYMPHADENOPATHY ; EDEMA

TEMPERATURE:- AFEBRILE

PR:74bpm

BP:140/90 mmHg 

RR:16cpm 

GRBS :- 66 mg/dl

SYSTEMIC EXAMINATION:- 

CVS:S1 S2+,NO MURMURS

RS:BAE+ ; NVBS ; No added sounds 

P/A:SOFT ; NON TENDER ; NO ORGANOMEGALY 

CNS :- 

Tone 

       Right                     Left 

U.L   N.                           N

L.L.   N.                           N

Power 

        Right   Left 

U.L    5/5.    5/5

L.L.    5/5.    5/5

Reflexes 

         Right     left 

B        +++.      +++

T.       +++.      +++

S.       +++        +++ 

K.        +++.      +++

A.              +.          + 

PLANTAR :- flexor.    Flexor 

PROVISIONAL DIAGNOSIS:- 

HYPOGLYCAEMIA secondary to OHA ? 

? CKD since 20 years 

HAEMOGLOBIN. 9.2 

TOTAL COUNT 5,600

NEUTROPHILS 78 

LYMPHOCYTES 17 

EOSINOPHILS 01 

MONOCYTES 04 

BASOPHILS 00

PCV. 28.7 

 

MCV 84.4 

MCH 27.1 

MCHC 32.1 

RDW-CV

15 

RDW-SD

46.6

RBC COUNT

3.40 

PLATELET COUNT 2.03 

RFT :- 

Urea :- 54 

Creatinine:- 2.7 

Sodium :- 137

Potassium:- 3.5

Chloride :- 111 

Total Bilirubin 0.58 

Direct Bilirubin 0.18

ALKALINE PHOSPHATE  646 

TOTAL PROTEINS :- 6.4 

ECG :- 

CXR :- 

DIAGNOSIS:- 

HYPOGLYCAEMIA secondary to OHA ? CERVICAL MYLEOPATHY ; NEUROGENIC BLADDER 

?AKI ON  CKD K/C/O DM since 6 MONTHS 

TREATMENT :- 

1. WITHHOLD OHA 
2. INJ 25 % DEXTROSE IV/STAT INFUSION @10 ml per hour depending on GRBS 
3. GRBS Hourly 
4. Monitor vitals 4 Th hourly