General Medicine
A 61 Year old male came to casuality with the altered sensorium and history of seizures.
23,August, 2022
on 20th,August
E LOG GENERAL MEDICINE
Hi, I am pindi Gayatri , 3rd Sem 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 patient's clinical problems with collective current best evidence based inputs.
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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.
CHIEF COMPLAINTS
A 61 year old male came to casuality with a history of seizures,and altered sensorium since 2 hours on 20th, August.
HISTORY OF PRESENT ILLNESS
He came to OPD with the chief complaints of itching of his right leg and feet.
He had cellulitis 2°to stasis eczema,ulcer leg (Right).
He had a history of seizures,and altered sensorium.
He had the history of vomiting 1 episode.
Altered sensorium is seen since 2 hours.
He had no history of fever.
Patient was apparently asymptomatic 3 years ago.Then he developed weakness for which he went to hospital and diagnosed with hypertension.
Since then he started to take the tablet TELMA-AM.But he was on irregular medication.
He came to OPD before with chief complaints of itching of right leg.
He was fine till the night before got admitted.
Then he had dinner and took hypertension medication.
He suddenly had brief loss of consciousness for 2 hours.
He was presented with hypoglycemia,
2° to OHA(glimepiride 1 mg/day since 16th August) intake has cellulitis associated with ulcer over right leg.
HISTORY OF PAST ILLNESS
He is a known case of hypertension since 3 years,but not on regular medication.
ASSOCIATED DISEASES
He is not a known case of Diabetes mellitus, Tuberculosis, epilepsy, Asthma,CAD,etc.
PERSONAL HISTORY
Married
Occupation-work in fields
Diet-mixed
Appetite-normal
Bowels-regular
Micturition-normal
No known allergies
Habits/addictions -alcohol occasionally
FAMILY HISTORY
No Diabetes
No hypertension
No Heart disease
No stroke
No cancers
No tuberculosis
No asthma or any other hereditary diseases
TREATMENT/DRUG HISTORY
Hypertension- On TELMA-AM medication
No Diabetes
No CAD
No Asthma
No Tuberculosis
No antibiotics
No hormones
No blood transfusion
No surgeries
GENERAL EXAMINATION
No pallor
No cyanosis
No icterus
No lymphadenopathy
No malnutrition
VITALS
Temperature-Afebrile
Pulse rate-62 per min
Respiratory rate-14 per min
Blood pressure- 110/70 mmHg
Spo2-98% at room air
GRBS-39 mg/dL
SYSTEMIC EXAMINATION
CVS
No thrills
S1S2 Cardiac sounds heard
No cardiac murmurs
RESPIRATORY SYSTEM
Position of trachea-central
Normal vesicular breath sounds heard
No dyspnea
No wheezing
ABDOMEN
Shape of the abdomen-scaphoid
No tenderness
No palpable masses
Hernial orifices-normal
No free fluid
No bruits
Non palpable liver
Non palpable spleen
No bowel sounds heard
CNS
Level of consciousness-conscious/alert
Speech-normal
Signs of meningeal irritation
No stiffness of neck
Kerning's sign:negative
INVESTIGATIONS
On 3rd ,August
He came to Dermatology OPD with complaints of itching of right leg.
Cellulitis 2°to stasis eczema
Also advised for foot end elevation.
They referred him to the general medicine OPD - In view of - ulcer dressing They also referred him to
general medicine OPD
In view of - serum creatinine-2.6 mg/dl
Albumin-+
Hb-10.8 gm/dl
GM - adviced for arterial doppler of
R-LL,FBS,PLBS
On 16th, August
He visited again the General surgery OPD,
With cellulitis associated ulcer(right) leg.
They adviced for doppler-arterial,venous
Swab for c/s
USG-abdomen(to rule out renal disease)
Then they have referred him to General Medicine OPD. In view of- uncontrolled sugars .
FBS -143mg/dl
PLBS-156mg/dl
(Denovo Diabetes mellitus)
Prescribed T.Glimi 1mg po,5 min before food
K/c/o-hypertension-irregular medication.
They adviced to visit nephrology op.
on 20th,August
MEDICATIONS/TREATMENT
PROVISIONAL DIAGNOSIS
Hypoglycemia under evaluation
FINAL DIAGNOSIS
Hypoglycemia
