SHORT CASE - FINAL PRACTICALS

This is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning. 

DEIDENTIFICATION - 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

Hall Ticket No.- 1701006116

CASE DISCUSSION -

A 75 year male resident of Chotuppal, farmer by occupation came to the causality with chief complaints of unresponsiveness since early morning 5am.

HOPI -

Patient was apparently asymptomatic 15 years back then he had fever, weakness and increased urine output then he visited local hospital and was diagnosed as Type 2 diabetes mellitus, prescribed medicine Glimda-MV 2.

On 6/6/22-

He didn't eat properly and went to sleep, his wife noticed he was sweating while sleeping, and was not responding properly to her.

On 7/6/22-

He was unconscious, and not able to speak since 5 am and was presented to our hospital at 10;35 am at that time his GRBS was 43 mg/ dl.

Since last 2 days he had not taken meals and consumed alcohol.

C/o excessive sweating, generalized weakness, fatigue, lethargy.

No c/o blurring of vision, headache, nausea, abdominal pain.

Past History -

Diagnosed with Type-2 Diabetes Mellitus 15 years back.

Not a k/c/o HTN, CAD , Asthma, epilepsy, TB.

Treatment History -

Glimda MV-2

(Combination of Metformin 500mg + Voglibose 0.2 mg + Glimeperide 2mg)

Personal History -

Married

Diet: mixed

Appetite: normal

Bowel movements: normal

Bladder movements: normal

addictions: consumes alcohol occasionally.

Family History -

No similar complaints in the family,

General Examination -

Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.

he is conscious, coherent and cooperative.

Built & nourishment- Moderate

No pallor 

No cyanosis

No icterus

No clubbing

No edema

No lymphadenopathy

Systemic Examination -

CVS : 

S1 S2 present

No murmurs

RESPIRATORY SYSTEM;

Chest - Elliptical

B/l symmetrical chest

Trachea - Central

B/l air entry present

NVBS heard

ABDOMEN:

Shape of abdomen: scaphoid.

Soft, non tender, no organomegaly present.

No rigidity or guarding.

CNS :

Cranial nerves , motor system , sensory system - Normal 

Reflexes - Normal

Investigations-

On 10/06/22-

Provisional Diagnosis-

Altered Sensorium secondary to Oral Hypoglycemic Agent induced hypoglycaemia.

Treatment-

IV fluids DNS @50 ml/hr infusion

Inj Optineuron 1 amp in 100 ml/NS/ IV / OD

Inj 25% dextrose IV/sos if GRBS < 70mg/dp

TAB Pantop 40 mg/ Po/ Od

GRBS monitoring hourly

Inform of if GRBS < 70 mg/dl

Strict I /O charting