28 year old with headache and decreased resoponsivness

 This is an online E log platform to discuss our patient's   de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

Introduction

- Patient aged 28years was bought to casuality with h/o giddiness and headache and decreased reaponsivness.

-History of ratpoison consumption 4days back and discharged back.

Chief complaints

-Pt has h/o zinc posphide poisoning on 3rd june 2022 and pt was admitted on 3rd june and was treated conservatively and was discharged on 6th june.

-Pt was normal on 6th and 7th june.

HISTORY OF PRESENT ILLNESS

• On 8th june Pt had headache and decreased appetite and 1 episode  of fever, no chills 
-Then pt went to bed and had history of difficulty in speech and altered behaviour.
-No h/o of seizures and vomitings,focal neurological defecit.

HISTORY OF PAST ILLNESS 

•NO H/O fever, pain abdomen, vomitngs, abdomen distension, pedal edema.

PERSONAL HISTORY

•Mixed diet

  Appetite Normal

•Sleep adequate

•Bowel and Bladder movements regular.

TREATMENT HISTORY 

 • Not k/c/o diabetes, HT, CAD , asthma, TB.

•NO H/O chemo /radiation , blood transfusion.

•NO H/O previous surgeries.

FAMILY HISTORY 

• Not significant.

GENERAL EXAMINATION

•Patient is conscious, coherent and cooperative

•Moderately built and Moderately nourished

•No signs of - Pallor

                       Cyanosis

                       Clubbing

                       Icterus


VITALS


•Temp - 98.4F
•Pulse rate - 112 BPM
•RP - 30/min
•BP - 120/80 mm hg
•SPO2 - 96


SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

•S1, S2 heard

•No murmurs

RESPIRATORY SYSTEM:

•NVBS heard

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - scaphoid

•No Tenderness

•No palpable mass

•No free fluid

•Spleen and liver not palpable

CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected

CEREBRAL SIGNS

• Unable to examine as patient was drowsy.


INVESTIGATIONS 









 
























PROVISIONAL DIAGNOSIS

- Zinc phosphide Poisoning.

TREATMENT 


8/06/22

Rx

TAB NAPROXEN 250 mg po/bd

IVF-NS 100ml/hr

        RL 100 ml/hr

INJ PAN 40mg  /IV/OD

INJ OPTINGURON 1amp in 100 mlNS  IV/OD

TAB AMITRYPTILLENE 10 mg PO/SOS

O2 Inhalation /sos

Vitals monitoring 4th hrs

INFORM SOS


9-06-22

Rx

TAB NAPROXEN 250 mg po/bd

INF NS RR100ml/hr

INJ PAN 40 mg/IN/OD

INJ OPTINEURON 10mg /100ml NS IO/OD

TAB AMITRYPTALLINE 10mg PO/SOS

O2 INHALATION /SOS

VITALS MONITORING

INFORM SOS2

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