19 Lavanya blog spot ..case study




 The is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardian signed informed consent here we discuss our individual patient problems through a series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based inputs                                                

This eblog  blog also reflects my patient centered online learning portfolia and your valuable inputs on the comment box is welcome 

I have been this case to solve in an attempts to understand the topic of patient clinical data analysis        
''to develop my competency in reading and comprehencing clincal data included history ,clinical finding, investigation,and come up with diagnosis and treatment plan 

64 year old male tractor driver by an occupation was brought to opd  in a drowsy state                                        with a complaint of sudden drowsiness and confusions                                                                     

 
HOPI ; the patient who developed sudden drowsiness and confusion and he also taken to an rmp after which brought to hospital                                                                                                                               NO H/O FALL SEIZURES LIKE ACTIVITY , LOC FOCAL SIGNS OF WEAKNESS           
  HISTORY OF SIMILAR COMPLAINS IN THE PAST -ONE EPISODE 6 MONTHS AGO, OME EPISODE AN YEAR BACK                                                                                                                      
NOT k/c/o DM , HTN, TB ,ASTHMA , EPILEPSY, CAD  

DIET ; normal 
Appitite ;normal 
sleep ;adequate 
bowel and bladder movements -regular 
addictions-alcoholic since7 years ,consumes 180ml/day 

ON EXAMINATION ::
patient is drowy 
vitals -PR 96 bpm ,GRBS=116mg/dl 
No signs of pallor ,icterus , cyanosis , lymphadenopathy and edema


CVS  S1 ,S2 heard,no murmurs
RS-BAE+,NVBS heard,trachea central 
P/A-soft, non tender , bowel sounds heard.

CNS-Speech is normal 
Neck stifness present 
kernigs and brudzinski signs are absent 
CRANIAL NERVES -normal 
SENSORY SYSTEM -normal 
MOTOR SYSTEM - normal 

provisional diagnosis ; starvation / alcoholic ketoacidosis 

plan of management 
admitted in AMC 
INVESTIGATIONS sent -CBP,LFT,RBS, S. CREATININE ,S.ELECTROLYES ,ECG 





TREATMENT :: 

1 .INJ. THIAMINE 1 AMP IN 100ml 
NS  IV/OD 
2. INJ . OPTINEURON 1 AMP IN 100ML NS IV/OD 
3. TAB . PAN 40mg OD 
4. MONITOR BP ,PR, SPO2 TEMPERATURE 
5. OVERNIGHT 5% DEXTROSE 
6. GRBS MONITORING 2nd hrly .. 

                                                                        
                         

        





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