Hi, I am Shivraj Sontakke 5th semester 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 patients 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 comment box is welcome.
I've 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.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
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 .
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 :-
WITHHOLD OHA
INJ 25 % DEXTROSE IV/STAT INFUSION @10 ml per hour depending on GRBS
GRBS Hourly
Monitor vitals 4 Th hourly
