A 30year old male with unresponsiveness

A 30year old male barber by occupation with unresponsiveness

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 

Patient came in unconscious state @12:00pm.
Drooling of saliva(mild) noticed during presentation
At 12:00pm patient GRBS was 25mg/dl @ admission later 25D was given and GRBS increased to 283mg/dl and having hypoglycemic seizures .As per attenders he was unconscious since 10pm(attenders noticed tightening of tongue and snoring)

HOPI:
Patient was apparently asymptomatic 15 yrs back.Then he got addicted to alcohol since 15 yrs and also addicted to gutka due to peer pressure .On 30/7/2019 ,he was admitted to casualty in another hospital with complaints of pain in epigastric region and 2-3 episodes of vomitings and nausea since morning of 30/7/2019. On 5/8/19 he was diagnosed with Denovo HTN and later used no medication for HTN. On 16/12/2019 he complained of pain abdomen wich increased on taking food and he has a slight decrease in K+ levels 131 .On 31/07/2019 his amylase & lipase being 138&400mmol/L and lipid profile is normal. On 21/1/20 he has again c/o pain abdomen @ epigastric region for 2 days and 2 episodes of vomitings and on irregular medication for HTN and patient was diagnosed with Denovo DM and used medication (FBS:150mg/dl,PLBS:250mg/dl ,HBA1C :15.1 & CREAT & UREA :NORMAL).On 25/1/20 amylase:100 & lipase 78(increased) DM since 2 yrs & HTN (on irregular medication) since 3 yrs and on usg diagnosed as acute on chronic calcific pancreatitis,ESR raised,RBS is 490mg/dl,electrolytes,LFT,UREA,CREAT normal

PERSONAL HISTORY
Barber by occupation.
Alcohol-regular
Tobacco:Gutka chewing
GENERAL EXAMINATION:  no pallor, icterus , cyanosis, clubbing , lymphadenopathy , edema 
Temp : 97.4 f
Pr :110 bpm
Bp:140/90 mmhg
Spo2: 99%
SYSTEMIC EXAMINATION :
RS : Bilateral air entry decreased , normal vesicular breath sounds , 
 
P/A : soft , non tender , bowel sounds present
 
CVS : S1 S2 present , no murmurs 

CNS : GCS:E2V1M4

INVESTIGATIONS

Lipase
Amylase
EEG -           NORMAL.                                
 
PROVISIONAL DIAGNOSIS:
?Hypoglycemic seizures with chronic pancreatitis
Treatment given:
1.Inj.Thiamine iv/od
2.IVF NS,DNS @100ml/he
3.Inj.Optineuron in 1pint NS
4.Inj.Neomol1gm/SOS/IV


SOAP NOTES:20/4/22
ICU BED 1

S:
Pt. In unconscious state
O:
Patient is not conscious,not cohorent 
Temp:97.4 F
BP:140/90 mm Hg
PR:110bpm
Spo2:99%

PER ABDOMEN :soft , non tender , bowel sounds present
 CVS : S1 AND S2 HEARD , NO MURMURS
RS: BAE decreased
CNS: E2V1M4
A:?Hypoglycemic seizures with chronic pancreatitis
P:
1.Inj.Thiamine iv/od
2.IVF NS,DNS @100ml/he
3.Inj.Optineuron in 1pint NS
4.Inj.Neomol1gm/SOS/IV

SOAP NOTES:21/4/22
ICU BED 1

S:
No fresh complaints
O:
Patient is conscious, cohorent ,coperative
Temp:97.4 F
BP:120/90 mm Hg
PR:102bpm
Spo2:96%

PER ABDOMEN :soft , non tender , bowel sounds present
 CVS : S1 AND S2 HEARD , NO MURMURS
RS: BAE decreased
CNS: E4V5M6
A:?Hypoglycemic seizures with acute on chronic pancreatitis
P:
1.Inj.Thiamine 100mg iv/bd
2.Inj.PAN 40mg IV OD
3.INJ.ZOFER 4 mg IV BD
4.INJ.LORA 2cc SOS
5.IVF NS,DNS @100ml/he
6.PR/BP/SPO2 monitoring
7.Syp.ASCORIL-D 100ml/TID
8.Ryles feeding
9.monotor GRBS 6th hrly
10.CINOD-T 10/40mg/OD

22/4/22
SOAP NOTES:
AMC BED 3

S:
No fresh complaints
O:
Patient is conscious, cohorent ,coperative
Temp:97.6F
BP:110/80 mm Hg
PR:98bpm
Spo2:98%

PER ABDOMEN :soft , non tender , bowel sounds present
 CVS : S1 AND S2 HEARD , NO MURMURS
RS: BAE present
CNS: E4V5M6
A:?Hypoglycemic seizures with acute on chronic pancreatitis
P:
1.Inj.Thiamine 100mg iv/bd
2.Inj.PAN 40mg IV OD
3.INJ.ZOFER 4 mg IV BD
4.INJ.LORA 2cc SOS
5.IVF NS,DNS @100ml/he
6.PR/BP/SPO2 monitoring
7.Syp.ASCORIL-D 75ml/TID
8.Ryles feeding
9.CINOD-T 10/40mg/OD


23/4/22
SOAP NOTES:
AMC BED 3

S:
No fresh complaints
O:
Patient is conscious, cohorent ,coperative
Temp:98.6F
BP:120/80 mm Hg
PR:98bpm
Spo2:98%

PER ABDOMEN :soft , non tender , bowel sounds present
 CVS : S1 AND S2 HEARD , NO MURMURS
RS: BAE present
CNS: E4V5M6
A:?Hypoglycemic seizures with acute on chronic pancreatitis
P:
1.Inj.Thiamine 100mg iv/bd
2.Inj.PAN 40mg IV OD
3.INJ.ZOFER 4 mg IV BD
4.INJ.LORA 2cc SOS
5.PR/BP/SPO2 monitoring
6.Syp.ASCORIL-D 75ml/TID
7.CINOD-10/40 mg/od

24/4/22
SOAP NOTES:
Ward

S:
No fresh complaints
O:
Patient is conscious, cohorent ,coperative
Temp:98.6F
BP:120/80 mm Hg
PR:98bpm
Spo2:98%

PER ABDOMEN :soft , non tender , bowel sounds present
 CVS : S1 AND S2 HEARD , NO MURMURS
RS: BAE present
CNS: E4V5M6
A:?Hypoglycemic seizures with acute on chronic pancreatitis
P:
1.Inj.Thiamine 100mg iv/bd
2.Inj.PAN 40mg IV OD
3.INJ.ZOFER 4 mg IV BD
4.INJ.LORA 2cc SOS
5.PR/BP/SPO2 monitoring
6.Syp.ASCORIL-D 75ml/TID
7.CINOD-10/40 mg/od
8. 7. GRBS monitoring


24/4/22
SOAP NOTES:
Ward

S:
No fresh complaints
O:
Patient is conscious, cohorent ,coperative
Temp:98.2F
BP:120/70 mm Hg
PR:88bpm
Spo2:98%

PER ABDOMEN :soft , non tender , bowel sounds present
 CVS : S1 AND S2 HEARD , NO MURMURS
RS: BAE present
CNS: E4V5M6
A:?Hypoglycemic seizures with acute on chronic pancreatitis
P:
1.Inj.Thiamine 100mg iv/bd
2.Inj.PAN 40mg IV OD
3.INJ.ZOFER 4 mg IV BD
4.INJ.LORA 2cc SOS
5.PR/BP/SPO2 monitoring
6.Syp.ASCORIL-D 75ml/TID
7.CINOD-10/40 mg/od
8. 7. GRBS monitoring

26/4/22
SOAP NOTES:
Ward

S:
No fresh complaints
O:
Patient is conscious, cohorent ,coperative
Temp:98.4F
BP:120/80 mm Hg
PR:92bpm
Spo2:98%

PER ABDOMEN :soft , non tender , bowel sounds present
 CVS : S1 AND S2 HEARD , NO MURMURS
RS: BAE present
CNS: E4V5M6
A:?Hypoglycemic seizures with acute on chronic pancreatitis
P:
1.Inj.Thiamine 100mg iv/bd
2.Inj.PAN 40mg IV OD
3.INJ.ZOFER 4 mg IV BD
4.INJ.LORA 2cc SOS
5.PR/BP/SPO2 monitoring
6.Syp.ASCORIL-D 75ml/TID
7.CINOD-10/40 mg/od
8. 7. GRBS monitoring

24/4/22
SOAP NOTES:
Ward

S:
No fresh complaints
O:
Patient is conscious, cohorent ,coperative
Temp:98.6F
BP:120/80 mm Hg
PR:98bpm
Spo2:98%

PER ABDOMEN :soft , non tender , bowel sounds present
 CVS : S1 AND S2 HEARD , NO MURMURS
RS: BAE present
CNS: E4V5M6
A:?Hypoglycemic seizures with acute on chronic pancreatitis
P:
1.Inj.Thiamine 100mg iv/bd
2.Inj.PAN 40mg IV OD
3.INJ.ZOFER 4 mg IV BD
4.INJ.LORA 2cc SOS
5.PR/BP/SPO2 monitoring
6.Syp.ASCORIL-D 75ml/TID
7.CINOD-10/40 mg/od
8. 7. GRBS monitoring


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