40 year old male patient with history of high grade fever and altered sensorium secondary to ? Cerebral malaria....? Viral malaria
MEDICINE CASE DISCUSSION
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M Rambai ,8 th semester
Roll number 78
Under the guidance of dr.chandana ma'am.
I've 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 a diagnosis and treatment plan.
CASE
A 40 year old male patient came to OPD with complaints of stary look and loss of awareness
HISTORY OF PRESENT ILLNESS
40year old male Diabetic since 4years on insulin mixtard and h/o RTA and post craniotomy 4years ago ,h/o emperical ATT used 8months ago when he had SOB,now came with c/o staring look for 5mins 8hrs ago with loss of awareness for 5mins,drooling of saliva, without any involuntary movements of limbs,no deviation of mouth,no involuntary micturation or defecation,after that patient is altered,irritable,not obeying commands
Patient did not take insulin for 3days due to non availability of drug
When he presented his bp was 180/100 and he is not a k/co HTN,rbs was 600,urine for ketones negative
Temp was 103F
Patient was on Anti tubercular therapy for 6 months,8 years back.
Patient is a known case of diabetic since 4 years ,for which he is on regular medication.
PERSONAL HISTORY :
Diet - Mixed
Appetite - Normal
Sleep - adequate
Bowel and Bladder movements - Regular
Addictions - alcoholic ( daily 90 ml)
Ghutkha - daily
Allergies - None
FAMILY HISTORY
No significant family history
GENERAL EXAMINATION :
The patient was not conscious, not coherent .
He is not well oriented to time, place and person.
No pallor
No icterus
No clubbing
No cyanosis
No generalized lymphadenopathy
No bilateral pedal edema
VITALS
Temperature :afebrile
Pulse : 90bpm
Blood pressure : 170/100 mm hg
Respiratory rate : 20 cycles / min
Spo2 : 99%on room air
SYSTEMIC EXAMINATION :
Cvs : S1 S2 heart sounds heard, No murmurs
Respiratory system : Bilateral air entry present.
Abdomen : Soft and non - tender. Bowel sounds are heard. No organomegaly.
CNS.
Level of consciousness - Drowsy
Speech - Normal
No signs of menigeal irritation
Motor system - moving all limbs
Glassgow scale - E4V3M4
REFLEXES
CBP
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