A 65 year old male with altered sensorium

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65Y OLD WITH ALTERED SENSORIUM

65Y OLD WITH ALTERED SENSORIUM

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 

PATIENT CAME WITH C/O ALTERED SENSORIUM SINCE 5AM (2/2/22), SOB GRADE IV SINCE TODAY MORNING. 

HE WORKS IN SEWING INDUSTRY , DAILY HE WORKS FOR 8 HRS AND STOPPED WORKING SINCE 2 YEARS

HOPI: 

PATIENT WAS APPARENTLY ASYMPTOMATIC 20Y BACK, PATIENT WENTTO REGULAR CHECKUP AND CAME TO DIAGNOSE WITH DM-II.

18 YRS BACK HE HAD H/O TRAUMA ON LEFT LITTLE TOE AND DUE TO  CELLULITIS ,LEFT LITTLE TOE HAS BEEN AMPUTATED.






SIX YRS BACK PATIENT AGAIN DEVELOPED LEFT LL CELLULITIS FOR WHICH FASCIOTOMY HAS BEEN DONE, SINCE THEN INSULIN HAS BEEN STARTED,MIXED INSULIN (30/70)35U -x-30U ,

LINAGLIPTIN 2.5MG/MF- 500MG AS DOCTORS MENTIONED  RAISE OF CREATININE. (NO REPORTS AVAILABLE).

DAPAGLIFOZIN 10 MG WAS ADDED.

NO C/O CHEST PAIN, PALPITATIONS, ORTHOPNEA, PND.

C/O BURNING MICTURITION SINCE 2 DAYS.

H/O COVID-19 20 DAYS BACK


PAST HISTORY:  

PAST MEDICAL HISTORY :

KNOWN CASE OF DM SINCE 20 YRS.

HE IS  A KNOWN CASE OF HTN SINCE 15 YEARS , NOT A KNOWN CASE OF BA, TB, THYROID.NO KNOWN DRUG ALLERGIES.

PAST SURGICAL HISTORY:

HE UNDERWENT  LENS IMPLANTATION SURGERY 10 YEARS BACK FOR LEFT EYE FIRST AND FOR RIGHT EYE 2 YEARS AFTER THAT OF LEFT EYE.


PERSONAL HISTORY:

DIET - MIXED,

APPETITE -NORMAL ,

BOWEL MOVEMENT - REGULAR , PASSED STOOLS YESTERDAY

BLADDER MOVEMENTS - REGULAR, ADDICTIONS : He consumes alcohol occasionally

Smoking: He does not smoke

NO KNOWN DRUG ALLERGIES


FAMILY HISTORY: NOT SIGNIFICANT

TREATMENT HISTORY: 

Inj.25D IV/STAT 

PATIENT IS CURRENTLY ON

T.CLINIDIPINE 10MG/PO/BD


ON EXAMINATION 

PATIENT HAS ALTERED SENSORIUM

SIGNS OF  PALLOR +, PEDAL EDEMA + 

NO ICTERUS, CYANOSIS, CLUBBING OF FINGERS.


VITALS: 

PR: 110 BPM

BP:180/80 MMHG

SPO2: 94% ON RA

GRBS: 33MG%-->225 MG%



SYSTEMIC EXAMINATION: 

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS HEARD

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS HEARD

PER ABDOMEN: 

SHAPE OF THE ABDOMEN : OBESE 

SOFT, NONTENDER, NO ORGANOMEGALY 



CNS: PATIENT WAS DROWSY INITIALLY WITH SLURRED SPEECH 


 INVESTIGATIONS:

RAT : NEGATIVE

RTPCR : NEGATIVE

SEROLOGY:NEGATIVE

HEMOGRAM: 

HB: 14.5

TLC: 9.600

N/L/E/M/B: 94/03/01/02/00

PCV: 42.1

MCV: 85.4

MCH: 29.4

MCHC:34.4

RBC:4.93

PT:1.30

RDW-CV :13.6

RDW-SD: 43.2

PS: NC/NC IMP: ABSOLUTE NEUTROPHILIA WITH MILD THROMBOCYTOPENIA

RFT:

BLOOD UREA : 46 MG/DL

SERUM CREATININE: 1.9

SERUM ELECTROLYTES:

Na+ : 138

K+: 5.7

Cl-: 103

LFT

TB: 0.96

DB: 0.22

SGOT:49

SGOT:40

ALP:206

TP:6.3

ALBUMIN:3.8

A/G: 1.53

 USG: IMP: B/L GRADE-1 RPD



ECG: 

CXR: 


PROVISIONAL DIAGNOSIS: 

HYPOGLYCEMIA SECONDARY TO OHA.

TREATMENT PLAN:

T.CLINIDIPINE 10MG/PO/BD


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