GM case study

 Anvitha reddy 

Roll no .06

Below is an elog describing patient centered data approach and discussion regarding patient deidentified health data.

CHIEF COMPLAINTS

A 75 year male patient from chotuppal came to causality with chief complaints of unresponsiveness and unable to speak. 

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 4 days back. Then skipped his breakfast and his medicine ( voglibose, metformin, glimiperide) due to other works. Then he became unresponsiveness on 6/06/22 morning. Then was taken to hospital.

 HISTORY OF PAST ILLNESS

He was apparently asymptotic 6 years back. Then he went to hospital due to decreased responsiveness and was diagnosed as DM -II.

He is n/k/c/o HTN, CAD , Asthma, epilepsy, TB

PERSONAL HISTORY

Married

Diet: mixed

Appetite: normal

Bowel movements: normal

Bladder movements: normal

Alcoholic ( drinks intermittently)

Non smoker

FAMILY HISTORY

Not a k/c/o asthma , TB, epilepsy, diabetes, HTN, CAD

GENERAL EXAMINATION

Moderately built, moderately nourished and 

No pallor 

No cyanosis

No icterus

No clubbing

No edema

No lymphadenopathy

SYSTEMIC EXAMINATION

CVS : 

No thrills 

no murmurs

S1 S2 present

RESPIRATORY SYSTEM:

No dyspnoea

No wheeze

Position of trachea is central

Breath sounds is vesicular

ABDOMEN:

Shape of abdomen: scaphoid

No tenderness

No palpable mass

Hernial orifices are normal

No free fluid 

No bruits

Liver: not palpable

Spleen: not palpable

Bowel sounds : yes

CNS :

No stiffness

No kernigs sign

Cranial nerves , motor system , sensory system, Glasgow scale are normal

PROVISIONAL DIAGNOSIS:

Altered sensorium secondary to OHA induced hypoglycaemia.

CKD (diabetic nephropathy)

INVESTIGATIONS ORDERED :

On 7/06/22




 




On 8/06/22:


TREATMENT:

IV fluids DNS @50 ml/hr continuous 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 help

Inform of if GRBS < 70 mg/dl

Strict I /O charting













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