61 year old male with 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 patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

New admission, icu bed 4
61 Yr male , 

C/C
Came with chief complaints of brief loss of consciousness on 19/08/22. His GRBS on admission was 39mg/dl. After connecting on 25D he regained his consciousness.

HOPI
Pt was apparently asymptomatic 3 yrs back Then he developed weakness for which he went to hospital & diagnosed with HTN & was started on Tab. TELMA- AM . But was on irregular medication. Then he was fine till yesterday night. Then he had dinner & took HTN medication. Then he suddenly had brief loss of consciousness for 2 hrs

PH
K/c/o HTN Since 3 yrs ( not on regular medication) 
Not a k/c/o DM , TB , Epilepsy ,Asthma ,Thyroid.

Personal History
Diet: Mixed
Appetite:Normal
B&B :Regular
Sleep: Adequate
Micturition: Normal
No allergies
Addictions:Occasionally takes alcohal

Family History
No Family History of DM HTN Asthma Cardiac diseases.

Treatment History
On irregular treatment of HTN 
Takes tab Telma .

S :he is concious 

General Examination 
Pt. Is concious , coherent and copertative.
No Pallor
No Icterus
No Cyanosis 
No Lymphadenopathy
PR 67bpm
RR 18cpm
TEMP : 97.9°F
BP 110/80 mmHg
SpO2 98%
GRBS 39 gm/dl

Systemic Examination 
RS: BAE+, clear No wheeze ,dyspnoea.
CVS: S1 S2 + , NO added sounds or murmers.
P/A: soft and non tender No organomegaly.
CNS : No focal Neurolical deficit.

Provisional diagnosis
Hypoglycemia secondary to OHA under evaluation.

Investigations


provisional diagnosis: hypoglycemia secondary to OHA  under evaluation. 

Treatment
1. IVF DNS @75 ml/hr 
2. Hourly GRBS MONITORING

21/08/22
S : no fresh complaints 

O
Pt. Is concious, coherent, cooperative 
PR 68bpm
RR 18cpm
TEMP : 98.7 F
BP 120/80 mmHg
RS: BAE+, clear 
CVS: S1 S2 + , NO added sounds 
P/A: soft and non tender. 
CNS : NAD 

A Hypoglycemia under evaluation

Plan of treatment 
1. Stop OHA
2. IV fluids 25% dextrose infusion @ 10ml/ hr
3. Hourly GRBS monitoring
4.tab. telma 40mg po/od
5. Megaheal ointment for leg ulcer/tid
6. Bp/pr/temp monitoring 8th hourly 


22/08/22
S:No fresh complaints

O
Pt. Is conscious coherent and copertative.
PR 74bpm
RR 17/min
TEMP 98.5 F
BP 130/80 mmHg
RS BAE+,clear
CVS S1S2 + No added sounds
P/A soft and non tender
CNS  NO Neurolical abnormalities 
GRBS @ 8 am 96mg/dl


Plan of treatment
1.Stop OHA
2.IV fluids 25% Dextrose infusion @10ml/hr 
3.Tab .Telma 40mg / po/ OD
4.Megaheal Ointment for L/A /BD
5.Hourly GRBS Monitoring
6.BP / Temp/ PR charting 8 hourly


23/08/22

S : No fresh complaints

O
Pt. Is conscious coherent and copertative
PR 78 BPM
RR 18 cpm
TEMP 98.7
BP 120/70mmHg
RS :BAE + ,clear
CVS: S1,S2 Heard , no added sounds
CNS :NO abnormalities 
P/A Soft and non tender
GRBS @ 8 am 134mh/dl

Plan of treatment
1.Stop OHA
2.Tab Telma 40 mg /po/OD
3.Megaheal Ointment for L/A BD
4.Hourly GRBS Monitoring
5.Bp/ Temp / PR monitoring every 8 hourly



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