MEDICINE BLOG

-103 Pavan


This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

 I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including, history, clinical findings ,investigations, come up with a diagnosis and treatment plan.



A 47 yr old male from lingotam driver by occupation came to OPD on 18/06/2023 with chief complaints of:

-unresponsiveness since 5:00 AM on 18/06/2023
-Burning sensation on passing urine since 3 days
- profuse sweating since 5:00 AM on 18/06/2023

History of presenting illness:

Patient was apparently asymptomatic before 5:00 AM on 18/06/2023 then when he was going to washroom he had a dizzy feeling and fell to the ground and he was in a unresponsive state.

His wife then called RMP doctor and he suggested to give him some sugar,then was brought to casualty.

History of similar complaint one week ago and came to the casualty and he didn't want to get admitted into the hospital.

Patient complained of burning micturiton since 3 days.

No complaints of fever,cold,cough,vomiting,loose stools.

No complaints of shortness of breath,chest pain,palpitations,orthopnea,pnd.

Past history:


History of similar complaint one week ago and came to the casualty and he didn't want to get admitted into the hospital.

Patient is a known case of diabetes since 10 years.

Not a known case of Hypertension,epilepsy ,tuberculosis,asthma,cad,pedal edema,facial puffiness.

Family history:

No significant family history 

Personal history:

Marital status: married

Sleep: adequate 

Diet: mixed

Appetite:normal 

Bowel and bladder:regular and normal 

Addictions: Smoking since 20 years 10 cigarettes per day 


Daily routine:

Patient wakes up at 5:00 AM and goes for washroom then he sleeps again.

Then he wakes up again at 6:00 gets fresh and eats breakfast by 7 AM.

Then he takes formin SR 500 mg tablet

He is not going for work since 6 months

Aft by 12-1 PM he eats rice and vegetables dal occasionally

Then he sleeps till evening

Drinks tea in the evening 

Has dinner by 8:00 PM 

Sleeps by 9:00 PM

Surgical history :

No significant surgical history 

Treatment history:

Formin SR 500 daily once since 10 years

General examination:

Patient was conscious,coherent, cooperative well oriented to time,place and person 

No pallor,icterus,cyanosis,clubbing, lymphadenopathy,pedal edema 

Vitals:

Temperature: Afebrile

Pulse: 84 BPM

RR:16 cycles/min

BP: 110/80 mmHg

Systemic examination:

CVS:

S1,S2 HEARD 
NO MURMERS

Respiratory system:

Trachea Central in position 

B/L air entry present 

Normal vesicular breath sounds heard

Per abdomen:

Abdomen : scaphoid

Spleen non palpable

Liver non palpable

No tenderness

CNS:

No focal neurological deficit found 

Sensory:normal 

Motor: normal 

Bulk:Right arm :25 cm 
         Left arm : 25 cm 

         Right forearm: 22 cm
         Left forearm: 24 cm

         Right proximal muscles:33 cm
         Left proximal muscles: 33 cm

         Right distal muscles:29 cm
         Right distal muscles:29 cm

Cranial nerves: normal 

Investigations:



    
        REPORTS:-








Provisional diagnosis:

Induced hypoglycemia secondary to oral hypoglycemic drugs


Treatment:

Inj.25D 100 ML IV STAT

STOP OHA till further notice

GRBS MONITORING 

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