GM case 5

  1st August
Case Scenario.....
Hi,I am G.Amulya,3rd BDS student.This is an online eblog book to discuss our patients health data after taking his consent.this also reflux my patient centered online learning portfolio 
                Case History 
A 57 yrs old male came to the old with the chief complaints of:
c/o patient presented with Altered sensorium since yesterday evening to the casualty 
HISTORY OF PRESENT ILLNESS
Patient was apparently alright 3 days ago then he stopped inj MIXTARD SC/ BD since 3 days. And H/o irrelevant talk  Since yesterday.but able to recognise attenders
and No H/0 involuntary movements ,H/O low grade fever, since yesterday evening,
intermittant in nature, temporarily relieved on medication not associated with burning micturation, cold, cough, vomiting, loose stools

No C/O of SOB (shortness of breath), chest pain, palpitations, orthopnea, PND, pedal edema or decreased urine output 

3. HISTORY OF PAST ILLNESS

H/O similar complaints in feb2022, pt was admitted in our hospital and was diagnosed as HHS with diabetic nephropathy ,Pt had H/O High-grade fever chills for 4 days and H/O stoppage of  OHHS for 3days

K/c/o  DM-ll years-1.5 yrs

Kle/o Chronic pancreatitis  and chronic kidney disease , H/O pulmonary TB 2yrs ago ,used ATT for 6 months
4 .PERSONAL DETAILS
Diet - mixed 
Apatite- normal
Bowel and bladder - regular
Sleep- not adequate
Addictions - no
FAMILY HISTORY
No relevant complaints 
*GENERAL EXAMINATION
Patient is concious cooperative well oriented with time and place
Pallor-present
Icterus-absent
Cyanosis-absent
Clubbing -absent
Edema-absent
*VITALS
Temp-99.5°
Pulse rate-88 beats per minute
Respiration rate-20/min
BP-120/80 mm Hg
         PROVISIONAL DIAGNOSIS
            May has any CNS defect
Q/A
How much time it takes to recover?
Does the patient will be normal after the treatment?
How the patient will be treated?


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