A 55 year old woman with loss of consciousness

A 55 year old woman presented with sudden loss of consciousness

24 August 2022

E LOG GENERAL MEDICINE 

Hi, I am Nandini, 3rd Sem Medical Student.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 is welcome.”

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. 

CHIEF COMPLAINTS:

Patient presented with complaints of sudden loss of consciousness for 30 minutes.

She don't know any thing about this unless her family members told she fainted and they noticed sweating.

HISTORY OF PRESENT ILLNESS:

She was asymptomatic 20 days ago  and experienced the same. So, she went to nearby hospital. They told she is weak and to eat well. She diagnosed with hypertension but didn't took any medication.

PAST HISTORY:

Known case of diabetes since 2 years 

                     & hypertension 20 days back.

No history of tuberculosis, epilepsy,asthma,CAD.

She was diagnosed with kidney stones and undergone surgery 20 years back.

PRESENT HISTORY:

Diet: mixed(But consumes only mutton but not         

         chicken and egg)

Appetite: normal

Bowels : regular 

Bladder: regular

Sleep : adequate

Addictions:None

FAMILY HISTORY:

Mother passed away due to cancer.

ALLERGIC HISTORY:

No known allergies.

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Pallor is absent.

Icterus is absent.

No edema.

 VITALS:

Temperature: Afebrile 

PR: 60 bpm

RR: 20 cycles per minute

BP: 120/70 mm Hg

PO2: 95%

   

INVESTIGATIONS:

Ultrasound :

2D echo

 

ECG

        

                                GRBS:

                              268mg/dl( @ 4:15PM )

    Her blood glucose levels are fluctuating.

  Sometimes it is 550 mg/dl and once in range of 300 mg/dl and again comes in range of 60 to 200 mg/dl.