FINAL PRACTICAL EXAMINATION: SHORT CASE PRESENTATION

 Admission no. : 1701006109

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I've 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.

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever

CHIEF COMPLAINTS:

A 75 year old male farmer was brought to the department with the chief complaints of 

• Decreased responsiveness since 5 am on the day of presentation

HISTORY OF PRESENTING ILLNESS: 

Patient was asymptotic 15 years back. Then he developed weakness for which he went to the hospital and was diagnosed with Type 2 Diabetes mellitus. 

Patient had similar complaints of decreased responsiveness due to low grbs 6 years back and was treated for that in a local hospital. 

Patient gave a history of skipping his meals and Medicines (Metformin, Voglibose, Glimepride) since 2 days and which lead to his hypoglycaemic state. His wife noticed he was sweating in his sleep and was not responding to her. He was unconscious since 5 am and He presented to casualty at 10:35 am with a GRBS of 43mg/dl. 

Patient was on Metformin 500mg+Glimiperide 2mg+ voglibose 0.2mg since 15 years 

PAST HISTORY: 

K/O/C of diabetes since 15 years

NotK/O/C of HTN,CAD, ASTHAMA,EPILEPSY

Patient is alcoholic since 45 years

GENERAL EXAMINATION : 

• Patient is conscious , coherent and cooperative, moderately built and nourished and well oriented to time , place and person. 
• Pallor - Absent
• Icterus - Absent 
• Clubbing - Absent
• Cyanosis - Absent
• Lymphadenopathy - Absent
• Edema - Absent 

VITALS : 

• Temperature : Febrile
• Pulse : 71 beats per minute
• Respiratory rate : 20 cycles per minute
• Blood pressure : 160/100 mm of Hg
• SpO2: 97% @ room air
• RBS: 48 mg/dl

SYSTEMIC EXAMINATION

• CVS- S1, S2 sounds heard. No murmurs or thrills
• RS- Normal vesicular breath sounds, no wheezing, no dyspnoea, trachea central
• CNS- Sensory and motor systems intact. Normal muscle power, tone and reflexes
• P/A- Scaphoid shape, Soft and non tender, Bowel sounds heard, no palpable mass or hernia, no hepatomegaly of splenomegaly

INVESTIGATIONS : 

COMPLETE BLOOD PICTURE 

• Haemoglobin 10.5 gm/dl
• Total Count 7100 cells/cumm
• Neutrophils 53%
• Lymphocytes 35%
• Eosinophils 02 %
• Monocytes 10%
• Basophils 0%
• Platelet Count 3.88 lakhs/cu.mm
• Smear : Normocytic normochromic 

LIVER FUNCTION TESTS : 

• Total Bilirubin 0.52 mg/dl
• Direct Bilirubin 0.18 mg/dl
• SGOT(AST) 16 IU/L
• SGPT(ALT) 13 IU/L
• Alkaline Phosphate 95 IU/L
• Total Proteins 5.8 gm/dl
• Albumin 2.6 gm/dl
• A/g Ratio 1.65

RENAL FUNCTION TESTS : 

• Urea 17 mg/dl
• Creatinine 2.2 mg/dl

RANDOM BLOOD SUGAR : 

• RBS: 114 mg/dl 

COMPLETE URINE EXAMINATIONS :

ECG: 

ULTRASOUND :

PROVISIONAL DIAGNOSIS : 

Altered sensorium secondary to OHA (Oral Hypoglycaemic Agents) induced Hypoglycaemia

TREATMENT : 

Treatment Given

1)INJ.25% DEXTROSE IV/SOS/IF GRBS <70MG/DL

2)IV FLUIDS DNS @50 ML/HR CONTINUOUS INFUSION

3) INJ.OPTINEURON 1 AMP IN 100 ML NS/IV/OD

4) TAB PANTOP 40MG/PO/OD

Advice at Discharge: 

1)TAB PAN 40MG/PO/OD FOR 3 DAYS

2)TAB MVT PO/OD/ FOR 15 DAYS

3)STOP OHA'S IN VIEW OF HYPOGLYCEMIA

Follow Up: 

REVIEW AFTER 3 DAYS TO MEDICINE OPD FOR DIABETES MANAGEMENT

Preventive Care: 

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE.DONOT MISS MEDICATIONS.