74M GIDDINESS 5 hrs , Acute Hypotension, Diabetes Hypertension 15 years 6/10/2023

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 plan.

74 Y M came with complaints of giddiness since 5 hours 
HOPI
Patient was apparantly asymptomatic till today afternoon then he developed headache which relieved with medication then at evening he was unable to get up from toilet as he had profuse sweating with generalised weakness which decreased with medication from local doctor .Since then he is having headache and giddiness 
C/o B/L pedal edema ( pitting type; extending upto knee )
No c/o fever ; chest pain ; palpitations ; SOB , orthopnea, PND , vomitings ; loose stools .
H/O RTA to Rt. Knee and left knee Grade r osteoarthritis 
H/o cellulitis of right lower limb 

PAST H/0

K/C/O HTN since 15 years ( On Tab .Telma -H PO/OD )
DM Since 15 years (on Tab Glibanclamide 5mg + Metformin 500 mg Po/OD)
N/K/C/O CAD, CVA , TB, Asthma Epilepsy, Thyroid disorders.

PERSONAL H/O
Mixed diet
Normal Appetite
Bowel and bladder - regular
Sleep adequate 
Addictions - none

FAMILY H/O 
Not Significant 

GENERAL PHYSICAL EXAMINATION 
Patient is conscious; Coherent; cooperative 
Moderately built and nourished
No signs of pallor; Icterus; cyanosis; clubbing; generalised lymphadenopathy

BP-80/60 mm of Hg
PR- 97 bpm
GRBS- 160 mg/dl
RR- 16cpm
SPO2- 96 RA

 


SYSTEMIC EXAMINATION 
CVS - S1; S2 HEARD ,NO MURMURS 
RS- BAE+,NVBS +
PER ABDOMEN- 
OBESE ABDOMEN
SOFT; NONTENDER; NO ORGANOMEGALY

CNS - 
NORMAL

INVESTIGATIONS 

DIAGNOSIS-SEPTIC SHOCK WITH AKI LEFT LOWER LINB CELLULITIS 
K/C/O HTN SINCE 15 YEARS
T2 DM SINCE 15 YEARS

TREATMENT 
IV FLUID -0.9%NS@50ml/Hr
2.Inj.PIPTAZ 4.5 gm/IV/STAT
 FOLLOWED BY 2.25 gm /IV/QID
3.INJ.NORADRENALINE 2 Amp in 46 ml NS (0.16 mg/ ml) @ 1 ml/ hr to maintain MAP Greater than 65 mm Hg
4.Inj. ZOFER 4 MG IV / SOS
5.Inj. PAN 40 mg Iv/OD/ BBF
6. Inj. hAI S/C TID Acc to GRBS

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