CBBLE UDHC SIMILAR CASES
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.
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:
KNOWN CASE OF DM SINCE 20 YRS.
NOT A KNOWN CASE OF HTN, BA, TB, CAD.
PERSONAL HISTORY:
DIET - MIXED,
APPETITE -NORMAL ,
BOWEL MOVEMENT - REGULAR , PASSED STOOLS YESTERDAY
BLADDER MOVEMENTS - REGULAR, ADDICTIONS(ALCOHOL AND SMOKING) - NO ADDICTIONS
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:
PROVISIONAL DIAGNOSIS:
HYPOGLYCEMIA SECONDARY TO OHA.
TREATMENT PLAN:
T.CLINIDIPINE 10MG/PO/BD
SOAP NOTES
DAY 1:
AMC BED 1
S : Sensorium improved
No SOB
O :
O/E
No pallor/icterus/cyanosis/clubbing/ generalized lymphadenopathy/ pedal edema
Temp : Afebrile
PR : 88 bpm
RR : 22 cpm
BP : 150/100 mmhg
Spo2 : 98 % at RA
CVS : S1 S2 + , No murmurs
RS : bae + , clear
PA : soft, non tender GRBS :
8 AM : 285 - 12 HAI
10 AM : 121
2 PM : 324 - 16 HAI
4 PM : 229
8 PM : 225 - 14 HAI
10 PM : 324
2 AM : 202
8 AM : 225
A:HYPOGLYCEMIA SECONDARY TO ? OHA/ ? INSULIN WITH CKD SINCE 6 MONTHS AND DM SINCE 18 YEARS
P :
1. IVF NS 100ML/HR
2. INJ HAI SC/TID
acc to sliding scale
3. INJ. NPH SC/BD
4. GRBS CHARTING
5. TAB. CILNIDIPINE 10 MG/PO/OD
6. TAB. M6T XL 50 MG/PO/OD 7. BP/PR/TEMP/RR CHARTING 4TH HRLY
DOA:3
AMC BED 2
S : Sensorium improved
No SOB
O :
O/E
No pallor/icterus/cyanosis/clubbing/ generalized lymphadenopathy/ pedal edema
Temp : Afebrile
PR : 82 bpm
RR : 19 cpm
BP : 150/90 mmhg
Spo2 : 98 % at RA
CVS : S1 S2 + , No murmurs
RS : BAE + , clear
PA : soft, non tender
GRBS :
8 AM : 225 - 12 HAI+10R
10 AM : 224
2 PM : 142 - 10R
4 PM : 225
8 PM : 145 - 12N +10R
10 PM : 190
2 AM : 62 -25D
8 AM : 109 10N+10R
A:HYPOGLYCEMIA SECONDARY TO ? OHA WITH AKI ON CKD WITH HTN AND DM.
P :
1. IVF NS 100ML/HR
2. INJ HAI SC/TID
acc to sliding scale
3. INJ. NPH SC/BD
4. GRBS CHARTING
5. TAB. CILNIDIPINE 10 MG/PO/BD
6. TAB. MET XL 50 MG/PO/OD 7. BP/PR/TEMP/RR CHARTING 4TH HRLY
DOA: 4
AMC BED 2
S : Sensorium improved
No SOB
C/o 1 hypoglycemic episode at 2AM
No fever spikes
O :
O/E
No pallor/icterus/cyanosis/clubbing/ generalized lymphadenopathy/ pedal edema
Temp : Afebrile
PR : 88 bpm
RR : 23cpm
BP : 140/70 mmhg
Spo2 : 98 % at RA
CVS : S1 S2 + , No murmurs
RS : BAE + , clear
PA : soft, non tender
GRBS :
8 AM : 225 - 12 HAI+10R
10 AM : 224
2 PM : 142 - 10R
4 PM : 225
8 PM : 145 - 12N +10R
10 PM : 190
2 AM : 62 -25D
8 AM : 109 10N+10R
A:HYPOGLYCEMIA SECONDARY TO ? OHA WITH AKI ON CKD WITH HTN AND DM SINCE.
P :
1. IVF NS 100ML/HR
2. INJ HAI SC/TID
acc to sliding scale
3. INJ. NPH SC/BD
4. GRBS CHARTING
5. TAB. CILNIDIPINE 10 MG/PO/BD
6. TAB. MET XL 50 MG/PO/OD 7. BP/PR/TEMP/RR CHARTING 4TH HRLY
-PLAN TO DISCHARGE
ADVICE AT DISCHARGE
INJ HAI SC/TID 12-8-10
INJ. NPH SC/BD 10-X-10
TAB. CILNIDIPINE 10 MG/PO/BD
TAB.MET XL 50 MG/PO/OD
TAB.METHYLCOBALAMIN 1000MCG PO/OD
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