general medicine

HISTORY OF PRESENT ILLNESS:
A 50 year old male patient came to casualty with the complaint of tingling in both the legs as well as arms since one day, and even had the complaint of slurring of speech since 3 hrs.
patient is diabetic since past 10 years and has been incidentally diagnosed.
patient was asymptotic one day back but today morning he developed numbness and tingling in arms and legs for few hours which subsided. But started again at 3:00pm and also complains of slurring of speech.
No H/O vomitings, headache, blurring of vision
No H/O seizures, loss of consciousness.

SURGICAL HISTORY:

4years back due to trauma and uncontrolled Diabetes mellitus, patient 1st thumb and little finger were removed, later all other fingers were removed. since the surgery he is on Daily mixtard 25U once a day.

PAST HISTORY:
 DM since 10 years
 HTN since 6 years and on Tab Amlong 2.5
vitals:
temp: 98.4 F
PR: 93 BPM
RR: 18 com
BP: 130/90 mmHg
Spo2: 98% at RA
CVS: S1 S2 +, no murmurs
CNS: patient is conscious with slurred speech
cerebral signs- 1. finger nose coordination: normal
                          2. knee heel coordination: normal
 provisional diagnosis: 
TIA with uncontrolled sugars
 
CLINICAL IMAGES: 


Investigations:

ECG:
Cxr: 

TREATMENT: 
1- NBM till further orders
2- Allow only water
3- Inj HAI S/C 6U IV/ stat.>> Inj HAI IV infusion acc to algorithm
4- Inj Pan 40 mg IV / BD
5- Inj ondansetron 4 mg IV/ BD
6- IVF NS, RL@ 125ml/hr
7- Inj thiamine 1 Amp in 100 ml NS IV/BD
8- GRBS charting

Comments

Post a Comment

Popular posts from this blog

general medicine long case

Image
     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 and come up with a diagnosis and treatment plan.  CHIEF COMPLAINT:  65 years old male patient came to the casualty with chief complaint of shortness of breath since 5 days and distension of abdomen and pedal edema since 1 week HOPI: patient was apparently asymptomatic 1year back March 2022- patient was taken to private hospital with c/o shortness of breath, pedal edema, distension of abdomen and fever and was diagnosed to have renal failure and heart failure, and was started on conservative management. June 2022- patient had similar episodes and had HB of 5 approx and 20 prbc and transfusion was done diagnosed as anemia secondary to CKD  NO H/O of Male
Read more

General medicine

Image
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 and come up with a diagnosis and treatment plan. CHIEF COMPLAINT: A 45 year old female came to causality with a chief complaint of cough with sputum since 7days and shortness of breath since 7 days. HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 1 month back then she developed cough with sputum which aggrevated from 7 days. Sputum is mucoid, non blood stained , non foul smelling. Seasonal variation-cough is more during nights aggrevated on exposure to dust and cool air . Then she developed breathlessness from 7 days which is of grade-ll, gradual in onset, seasonal variation on exposure to dust and cool air.  Wheeze- present  No orthopnea, n
Read more

general medicine

Image
  This is an online E-blog to discuss our patient identified health data shared after taking the consent. Here we discuss our patient problems through series of inputs available. History of Present Illness: A 46 year old female patient came to hospital for dialysis Patient was apparently asymptomatic 5yrs ago when she underwent surgery for Right eye.This surgery wasn't successfull and the patient was on continuous pain since then. The patient then went for regular checkup 1 and 1/2 year ago was found out serum creatinine to be 6.0 and was on medication since  on jan 18th 2022 , the patient has severe shortness of breath (even at rest) and admitted at a local hospital , following serum creatinine was found to be 14.0 .So a fumoral line was placed for dialysis. she underwent dialysis for 4 times following the vein got clotted and it led to swelling of lower limb(left) and there was discolouration later she underwent 12 sessions of dialysis till now in various hospitals History of Pas
Read more