63y/M CAME TO CASUALTY WOTH LOSS OF CONSCIOUSNESS

This is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

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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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

Patient came to casuality with the history of loss of consciousness at 3 pm today . 

HISTORY OF PRESENTING ILLNESS :- 

Patient was approved asymptomatic till yesterday evening then her attenders  noticed she was in altered sensorium with intact consciousness by  the time they returned from work and today afternoon 3pm while eating patient lost consciousness( for 30 min) And was taken to the hospital and GRBS Was 56 ( hypoglycaemic) and was started on 25 % D And patient regained and intact sensorium since then and was brought here for further management.

C/O one episode of vomiting 

No complaints of fever ; vomitings ; loose stools ; pain abdomen 

Burning micturition; seizures 

PAST HISTORY:- 

Known case of DM Since 6 months ( on unknown medication) 

Known case of ? CKD since 20 yrs ( not on any medication)

Not a known case of HTN; CVA ; Thyroid ; TB ; asthma epilepsy .

PERSONAL HISTORY:-

Diet - mixed 

Appetite- normal

Sleep - adequate 

Micturition:- incontinence since 2 months 

Allergic history:- No history of any kind of allergies for food/drugs

Family history:- no significant family history 

GENERAL EXAMINATION:- 

PATIENT IS CONSCIOUS COHERENT AND CO OPERATIVE 

NO PALLOR ,ICTERUS; CLUBBING; CYANOSIS; ; LYMPHADENOPATHY ; EDEMA

TEMPERATURE:- AFEBRILE

PR:74bpm

BP:140/90 mmHg 

RR:16cpm 

GRBS :- 66 mg/dl

SYSTEMIC EXAMINATION:- 

CVS:S1 S2+,NO MURMURS

RS:BAE+ ; NVBS ; No added sounds 

P/A:SOFT ; NON TENDER ; NO ORGANOMEGALY 

CNS :- NFND

PLANTAR :- flexor. FlexorS

PROVISIONAL DIAGNOSIS:- 

HYPOGLYCAEMIA secondary to OHA ? 

? CKD since 20 years 

HEMOGRAM

HAEMOGLOBIN. 9.2 

TOTAL COUNT 5,600

NEUTROPHILS 78 

LYMPHOCYTES 17 

EOSINOPHILS 01 

MONOCYTES 04 

BASOPHILS 00

PCV. 28.7

MCV 84.4 

MCH 27.1 

MCHC 32.1 

RDW-CV15 

RDW-SD 46.6

RBC COUNT3.40 

PLATELET COUNT 2.03

RFT :- 

Urea :- 54 

Creatinine:- 2.7 

Sodium :- 137

Potassium:- 3.5

Chloride :- 111 

Total Bilirubin 0.58 

Direct Bilirubin 0.18

ALKALINE PHOSPHATE 64

TOTAL PROTEINS :- 6.4 

ECG :-