202307801

 

 


Case History and Clinical Findings

C/O 1 EPISODE OF LOC ON 18/2/23 AFTERNOON AROUND 12 PM HOPI:

PT WAS APPARENTLY NORMAL UNTIL AFTERNOON (18/2/23) THEN HE SUDDENLY HAD 1 EPISODE OF LOSS OF CONSCIOUSNESS FOR PERIOD OF 2 MINUTES AND THEN REGAINED CONCIOUSNESS.

NO H/O NAUSEA,VOMITINGS,HEADACHE,TRAUMA,ENT BLEED, DIMMING OF VISION. NO H/O CONFUSION,SEIZURES,CHEST PAIN,SOB

NO H/O INVOLUNTARY BOWEL AND BLADDER PASSAGE,TONGUE BITE PAST HISTORY:

K/C/O TYPE 2 DM SINCE 20 YEARS (ON T.GLIMI M1 PO/OD)

K/C/O HYPERTENSION SINCE 20 YEARS(ON T.MET-XL 50 MG PO/OD AND T.TELMA 40 MG PO/OD)

 

PT.SON GIVES H/O STOPPING MEDICATION FOR AROUND 20-30 DAYS 2 YEARS BACK K/C/O CKD SINCE 2 YEARS ON CONSERVATIVE MANAGEMENT

N/K/C/O CAD,CVA,TB,EPILEPSY,ASTHMA,THYROID DISORDERS

 

 

ON EXAMINATION:

PT IS C/C/C TEMP:97 F PR:74 BPM

BP:170/100 MM HG RR-18 CPM

 

RS: BAE +

NORMAL VESICULAR BREATH SOUNDS. CREPTS HEARD IN RIGHT IAA

CVS: S1S2+,NO MURMURS P/A: SOFT,NON TENDER CNS: HMF-INTACT

NO FOCAL NEUROLOGICAL DEFICIT

 

 

Investigation HEMOGRAM- HB-10.3

HB-10.3 TLC-10,100 PCV-29.7

PLATELET-3.30 LAKH RBS- 615 MG/DL

URINE FOR KETONE BODIES-NEGATIVE

 

 

ECG- TALL T WAVE SUGGESTIVE OF HYPERKALEMIA.

 

 

USG ABDOMEN-

B/L GRADE 2 RPD CHANGES

 

RT.KIDNEY-8*3.6 CM LT.KIDNEY-8.5*3.8 CM

URINARY BLADDER- PARTIALLY DISTENDED LIVER AND PANCREAS- NORMAL

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION<1.5 LIT/DAY INJ.LASIX 20 MG IV/BD

INJ.HAI S/C / TID /ACCORDING TO GRBS INJ.ERYTHROPOEITIN 5000 IU WEEKLY ONCE TAB.NICARDIA 10MG PO/BD

TAB.NODOSIS 500 MG PO/BD TAB.OROFER XT PO/OD TAB.SHELCAL 500 MG PO/OD TAB.BIO-D3 PO/OD

NEBULISATION WITH 2 RESPULES SALBUTAMOL MONITOR VITALS

Advice at Discharge

FLUID RESTRICTION<1.5 LIT/DAY TAB.LASIX 20 MG PO/BD 8AM-4PM INJ.HAI S/C / 10 U TID

8AM-1PM-8PM

10U-10U-10U

TAB.NICARDIA 10MG PO/TID 8AM-2PM-8AM TAB.NODOSIS 500 MG PO/BD AT 2PM TAB.OROFER XT PO/OD AT 2PM TAB.SHELCAL 500 MG PO/OD

LAMA NOTES:

PATIENT AND HIS ATTENDERS HAVE BEEN EXPLAINED ABOUT PATEINT CONDITION,RISKS INVOLVED WITH IT AND NEED FOR THEM TO STAY AND NEED FOR DIALYSIS IN THEIR OWN UNDERSTANDABLE LANGUAGE.BUT PATIENT AND HIS ATTENDERS DENIED THE ADVICE AND WANT TO LEAVE AGAINST MEDICAL ADVICE.

HOSPITAL STAFF AND DOCTORS HERE ARE NOT REPONSIBLE FOR ANY FURTHER DETERIORATION OF PATIENT CONDITION.

 


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