GM FINAL LONG CASE
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.
Feb 08,2022
A 55 year old male patient farmer by occupation presented to the casualty with chief complaints of altered sensorium since 1day and history of fever since 4 days.
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 4 days ago,then he developed high grade fever with no diurnal radiation and is associated with chills.
No h/o cough and enteric symptoms.
Attenders present there suggest that there was h/o stoppage of OHA for 3 days and there was decreased intake of food since he has fever.
H/o altered sensorium since 1 day
Irrelevant talk and not recognising attenders.
Able to move all 4 limbs
No h/o vomiting, diarrhoea , headache and seizures.
Initially took him to nalgonda and then shifted here for further management.
PAST HISTORY :
Known case of tuberculosis 2 years back and used anti- tubercular drugs for 6 months.
Known case of type 2 diabetes mellitus and is on OHA since 1 year.
No h/o hypertension and any cardiac attacks.
PERSONAL HISTORY:
Diet - Mixed
Appetite - Decreased appetite
Bowel movements - Regular
Bladder movements - Regular
Addictions - smoking since 30 years.
Regular intake of alcohol and stopped 2 years back since diagnosed with tb.
FAMILY HISTORY :
No relevant family history.
TREATMENT HISTORY :
On OHA since 1 year and used ATT for 6 months.
GENERAL EXAMINATION :
Patient is conscious, incoherent,non cooperative.
No icterus.
Pallor is present.
Clubbing is present.
No cyanosis, no lymphadenopathy, no edema.
VITALS :
Temperature : 97°F
Pulse rate : 98bpm
Blood pressure : 150/80 mm hg
Respiratory rate : 28 cpm
SpO2 : 97%
SYSTEMIC EXAMINATION :
CVS : S1,S2 heard , no murmurs.
RESPIRATORY SYSTEM : Bilateral Air Entry +ve vesicular breath sounds present , dyspnea present.
P/A : soft , non tender and no organomegaly.
CNS : Conscious, incoherent and non cooperative.
Bilateral Plantar extension present
Neck stiffness is present.
INVESTIGATIONS :
PROVISIONAL DIAGNOSIS :
Case of Altered Sensorium secondary to Diabetic Ketoacidosis.?
TREATMENT :
INJ. HAI 6U/IV/STAT
INJ. HUMAN ACTRAPID 1ML(40U)
INJ. THIAMINE 1 AMP in 100 ML NS/IV/OD
INJ. OPTINEURON 1 AMP in 100ML NS/IV/OD
GRBS MONITORING HOURLY
INJ. MONOCEF 2GM/IV/BD.
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