This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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 diagnosis and treatment
A 65 year old male, resident of nalgonda, farmer by occupation presented to the casualty with
CHIEF COMPLAINTS --1. Loss of consciousness, not waking up from the bed
2. Weakness in the body since 20 days
3. Loss of speech since 20 days
HISTORY OF PRESENT ILLNESS
The patient was apparently symptomatic 4 YEARS back when one day he collapsed beside the bed at 2:00 a.m. in the morning when he woke up to use the washroom
He complained of feeling giddiness which caused the fall. He was put back in the bed by his wife.
Next day morning when he woke up he fell down the bed again due to malaise and weakness in his Limbs, he was conscious and responding well
Upon consulting an RMP he was given glucose and 2 injections
Futher they consulted another doctor, where he was diagnosed with diabetes mellitus and hypertension and was given medications for the same
He has been frequently visiting the same hospital and getting medications once every week or once every 2 weeks
3 YEARS back he was admitted in a hospital due to high fever, diagnosed to be dengue as stated by his wife
The patient was apparantly warned about his kidney being damaged during his frequent visits, which he didn't share with his wife.
30 days back, the patient started scolding and screaming at his wife at 4 am in the morning, but his speech was not clear
He was taken to a nearby hospital where they were told that his blood pressure is high and blood glucose level is low
He was treated and sent back home
7 days back he has visited our hospital with complaints of not being able to walk properly since 3 days, and he was asked to come the next day
The next morning he was unconscious and didn't wake up from his sleep, and was brought to the hospital in an ambulance
Umbilical hernia since birth/childhood?
He has complained of having back pain since 3 years for which he occasionally took medicines
He had constipation since 6 days before being admitted at our hospital
Comments
Post a Comment