Short case
08.02.22
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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
50 year old male brought to casuality with the chief complaints of altered sensorium since yesterday evening (since 15 hours).
History of one episode of vomiting yesterday morning.
History OF PRESENT ILLNESS :
patient was apparently asymptomatic 10years back and he developed giddiness and loss of consciousness and weakness and on routine check up he was diagnosed with diabetes
And on regular medication with Tab. Glimipride bd and has control over sugar levels
4 months back patient developed ulcers on his right foot due to a small accident . The ulcers are non healing and are spreading so he got his toes amputated .
4 days back he went to his relatives house and had a heavy lunch with non veg and also had 90ml of alcohol on that day and missed his medication of glimipride on that day
Since then the patient had abnormal behaviour , unable to identify family members, shouting and talking to self and didn't sleep the entire night and morning he had an episode of vomiting with food particles as contents, non-projectile, non-bilious.
No H/O Fever.
PAST HISTORY :
K/C/O DM since 10 years on T.GLIMI-M BD
He takes alcohol occasionally since 15-20 years - occasionally consumes 3-6 units of whiskey
Amputation of last 3 toes of right foot .
No H/O of hypertension
No h/o asthma
No h/o epilepsy
FAMILY HISTORY:
No relevant family history is seen in family members
PERSONAL HISTORY:
Diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movements- regular
Occasional alcohol intake +
No known allergies
GENERAL EXAMINATION:
Patient is conscious, cooperative but respondes late to the questions asked
GCS : E4V3M6
Pallor +
No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema
Mild dehydration +
No neck stiffness
Kernig and Brudzinski sign negative
Vitals at admission:
Temp.- Afebrile
PR- 91 bpm
RR- 24 cpm
BP- 220/110 mmHg
SpO2- 97% at RA
GRBS- 524 mg/dL
SYSTEMIC EXAMINATION:
CVS: S1S2 heard, no murmurs
RS: BAE+ NVBS+
P/A: Soft, Non-tender
CNS:
Patient is drowsy but arousable
Incoherent speech
Motor and sensory systems - couldnot be examined
Reflexes - could not be elicited
Treatment:
1. IVF - NS @ 125 ml/hr continuous IV
2. Inj. HAI 6U IV STAT
3. Inj. Thiamine 2 amp in 100 ml NS IV STAT followed by Inj. Thiamine 1 amp in 100 ml NS IV/OD
4. Inj. Zofer 4 mg IV SOS
5. Inj. Lorazepam 1 ml in 4 ml NS @ IV STAT
6. Inj. Monocef 1 gm IV BD
7. Foley's catheterisation
8. Tab. Nicardia 10 mg PO STAT
9. Vitals monitoring 4th hourly
10. GRBS monitoring every hour
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