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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