GM FINAL LONG CASE

GM FINAL LONG CASE

JULY 31,2022

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.

July 31,2022

A 55 year old male patient farmer by occupation presented to the casualty with chief complaints of altered sensorium since 1day and history of fever since 4 days.

HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic 4 days ago,then he developed high grade fever with no diurnal radiation and is associated with chills.

No h/o cough and enteric symptoms.

Attenders present there suggest that there was h/o stoppage of OHA for 3 days and there was decreased intake of food since he has fever.

H/o altered sensorium since 1 day 

Irrelevant talk and not recognising attenders.

Able to move all 4 limbs 

No h/o vomiting, diarrhoea , headache and seizures.

Initially took him to nalgonda and then  shifted here for  further management.

PAST HISTORY : 

Known case of tuberculosis 2 years back and used anti- tubercular drugs for 6 months.

Known case of type 2 diabetes mellitus and is on OHA since 1 year.

No h/o hypertension and any cardiac attacks.

PERSONAL HISTORY: 

Diet - Mixed 

Appetite - Decreased appetite

Bowel movements - Regular

Bladder movements - Regular

Addictions - smoking since 30 years.

Regular intake of alcohol and stopped 2 years back since diagnosed with tb.

FAMILY HISTORY :

No relevant family history.

TREATMENT HISTORY : 

On OHA since 1 year and used ATT for 6 months.

GENERAL EXAMINATION : 

Patient is conscious, incoherent, cooperative.

No icterus.

Pallor is present.

Clubbing is present.

No cyanosis, no lymphadenopathy, no edema.

VITALS : 

Temperature : 97°F

Pulse rate : 98bpm

Blood pressure : 150/80 mm hg

Respiratory rate : 28 cpm

SpO2 : 97%

SYSTEMIC EXAMINATION : 

CVS : S1,S2 heard , no murmurs.

RESPIRATORY SYSTEM : Bilateral Air Entry +ve vesicular breath sounds present , dyspnea present.

P/A : soft , non tender and no organomegaly.

CNS : Conscious, incoherent and cooperative.

Neck stiffness is present.

INVESTIGATIONS : 


























CLINICAL IMAGES : 






PROVISIONAL DIAGNOSIS : 

Diabetic Ketoacidosis

TREATMENT : 

INJ. HAI 6U/IV/STAT 

INJ. HUMAN ACTRAPID 1ML(40U)

INJ. THIAMINE 1 AMP in 100 ML NS/IV/OD 

INJ. OPTINEURON 1 AMP in 100ML NS/IV/OD 

GRBS MONITORING HOURLY 

INJ. MONOCEF 2GM/IV/BD.

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