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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan
CONSENT AND DEIDENTIFICATION :
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 through out the piece of work whatsoever
Under the guidance of
Dr. Vinay PGY3
Dr.Pavani PGY1
This is a case of 35 year old male, cable operator by occupation has presented to the casualty with the chief complaints of
Seizures since yesterday night
HOPI
The patient is apparently asymptotic 5 years back. He was diagnosed to be type 2 dm and was using metformin 500mg OD ever since
His last checkup for sugars was around 5 to 6 months ago
2DAYS AGO
Headache since 2 days associated with generalised weakness
YESTERDAY NIGHT
Lower and upper limb pain
Stiffness
Deviation of mouth towards left side
Involuntary movements for 20 to 30 sec first started in the left side and then became generalised
Froathing and tongue biting
Loss of consciousness for 3 min
Post ictal confusion for 5 min
Similar episodes 4 (2at home and 2 in ambulance)
Past history
Known case of diabetes since 5 years on metformin Po OD
Not a known case of htn/asthma/tb/CAD
PERSONAL HISTORY
DIET mixed
APETITE decreased since 1 week
BOWEL AND BLADDER MOVEMENTS normal
SLEEP adequate
ADDICTIONS alcoholic occasional
FAMILY HISTORY
not significant
GENERAL EXAMINATION
The patient is conscious coherent but not cooperative well oriented to time place and person
He is moderately built and nourished
Pallor absent
Icterus absent
Cyanosis absent
Clubbing absent
Edema absent
Lymphadenopathy absent
Vitals
Temp afebrile
Pr 82bpm
RR 18 cpm
GRBS
10am- 377mg/dl 6ml/hr
2pm- 152mg/dl 2ml/hr
6pm-170mg/dl 2ml/hr
8pm- 96mg/dl 2ml/hr
2am 84mg/dl
SYSTEMIC EXAMINATION
CVS-s1s2 +
Pa-soft and non tender
Rs-BAE+
Diagnosis: seizures under evaluation with type 2 dm denovo hypertension
Investigations
Fundoscopy
2d echo
25/8/2022
REPORTS 25/8
26/8/2022
ABG
PH 7.488
PCO2 29.8
Po2115
HCO3 24.9
27/8/2022
Treatment
1) inj HAI 1ml(400)+39 ml NS
2)inj levipil 500mg iv bd
3)inj thiamine 200mg in 100ml NS iv TID
4)inj zofer 4mg/iv/sos
5)inj pan 40 mg iv OD
6)BP/pr/rr/spo2 charting 2nd hourly
8) tab atorvas 20 mg Po OD
Soap notes
Day 2 25/08/2022
S:4 episodes of seizures
O: No seizure episode after admission
Patient is conscious,coherent and cooperative
PR-82bpm
RR-16cpm
BP-120/90mm
Temp-98.4f
GRBS
10am- 377mg/dl 6ml/hr
2pm- 152mg/dl 2ml/hr
6pm-170mg/dl 2ml/hr
8pm- 96mg/dl 2ml/hr
2am 84mg/dl
CVS-S1 and S2 +,no added sounds
R/S-BAE+,clear
P/A-soft and non tender
Cns- higher motor functions intact
A: Diagnosis: seizures under evaluation with type 2 dm denovo hypertension
P:
1) inj HAI 1ml(400)+39 ml NS
2)inj levipil 500mg iv bd
3)inj thiamine 200mg in 100ml NS iv TID
4)inj zofer 4mg/iv/sos
5)inj pan 40 mg iv OD
6)BP/pr/rr/spo2 charting 2nd hourly
8) tab atorvas 20 mg Po OD
Day 3 26/08/2022
S:4 episodes of seizures
O: No seizure episode after admission
Patient is conscious,coherent and cooperative
PR-82bpm
RR-16cpm
BP-150/90mmhg
Temp-98.4f
GRBS
8am-121mg/dl
10am- 306mg/dl
2pm- 246mg/dl
6pm-176mg/dl
8pm- 578mg/dl 10HAI and 6NPH
2am 179mg/dl
CVS-S1 and S2 +,no added sounds
R/S-BAE+,clear
P/A-soft and non tender
Cns- higher motor functions intact
A: Diagnosis: seizures under evaluation with type 2 dm denovo hypertension
P:
1) inj HAI SIC TID
2)inj levipil 500mg iv bd
3)inj thiamine 200mg in 100ml NS iv TID
4)inj zofer 4mg/iv/sos
5)GRBS monitoring acc to 7 point profile
6)BP/pr/rr/spo2 charting 2nd hourly
8) tab atorvas 20 mg Po OD
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