GENERAL MEDICINE ASSESSMENT


I am P. Sri Chandana

Roll. No: 98

Below is an E-log describing patient centered data approach and discussion regarding patient de- identified health data                                            this e log is made under the guidance of Dr madhumita (intern)

CASE HISTORY:

64 yr old male patient came to casuality 

CHIEF COMPLAINTS:

drowsiness 

Confusion in the afternoon after he came from work 

HISTORY OF PRESENT ILLNESS:

drowsiness 

HISTORY OF PAST ILLNESS:

no history of fall 

No history of seizure like activity,LOC

No history  of focal signs of weakness 

History of similar complaints in the past 

One episode 6 months ago 

One episode 1yr back 

N/k/c diabetes mellitus, hypertension, tb ,asthma ,epilepsy  ,CAD

PERSONAL HISTORY:

Diet- mixed

Appetite- normal

Sleep- adequate 

Bowel and bladder movements- regular

Addictions: alcoholic since 7 yrs, consumes 180ml per day 

GENERAL EXAMINATION:

Patient is drowsy

Vitals- PR=96bpm,

 RR= 16cpm

Temp= 96F

BP= 140/90

 GRBS= 116 mg/dl.

No signs of pallor, icteurs, cyanosis, Lymphadenopathy and edema. 


CVS- S1, S2 heard, no murmurs

RS- BAE+, NVBS  heard, trachea central 

P/A - Soft, non tender,  bowel sounds heard. 


CNS- Speech is normal.

Neck stiffness present. 

Kernigs and Brudzinski signs are absent.

Cranial nerves- normal

Sensory system - normal

Motor system -normal                                                                                                                                    INVESTIGATIONS: 




  

PROVISONAL DIAGNOSIS:

Starvation/alcoholic ketoacidosis. 

Plan of management:- 

Admitted in AMC.

Investigations sent- CBP, LFT, RBS, S. Creatinine, S. Electrolytes, ECG.

TREATMENT:

Treatment:-

1) Inj. Thiamine 1 amp in 100ml NS IV/TID

2) Inj. Optineuron  1 amp in 100ml NS IV/OD

3) Tab. Pan 40 mg OD

4) Monitor BP, PR, SPO2,  Temperature 

6) Overnight 5%dextrose 

7) GRBS monitoring 2nd hrly.

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