GM case study
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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