14-01-2026
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[4.17 pm, 14/01/2026] PPM 1: He was brought to us for the first time in August 2022 when @PPM3 was intern and his EMR summary from then is pasted below.
Age/Gender: 38 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 24/08/2022 03:53 AM
Discharge Date: 27/08/2022 11:12 AM
PGY3
PGY1
INTERN
INTERN
INTERN
Diagnosis
SEIZURES SECONDARY TO NON KETOTIC HYPERGLYCEMIA WITH UNCONTROLLED
DIABETES MELLITUS
DENOVO HTN WITH HYPERTENSIVE RETINOPATHY.
Case History and Clinical Findings
This is a case of 38 year old male, cable operator by occupation has presented to the casualty with
the chief complaints of Seizures since yesterday night
HOPI
The patient is apparently asymptomatic 5 years back. He was diagnosed to be type 2 dm and was using
metformin 500mg OD ever since.
His last checkup for sugars was around 5 to 6 months ago
2DAYS AGO
Headache since 2 days associated with generalised weakness
YESTERDAY NIGHT
Lower and upper limb pain, Stiffness, Deviation of mouth towards left side, Involuntary movements for 20 to 30 sec first started in the left side and then became generalised
Frothing and tongue biting
Loss of consciousness for 3 min
Post ictal confusion for 5 min
Similar episodes 4 (2at home and 2 in ambulance)
Past history
Known case of diabetes since 5 years on metformin Po OD
Not a known case of HTN/ASTHMA/TB/CAD
PERSONAL HISTORY
DIET mixed
APETITE decreased since 1 week
BOWEL AND BLADDER MOVEMENTS normal
SLEEP adequate
ADDICTIONS alcoholic occasional
FAMILY HISTORY
not significant
GENERAL EXAMINATION The patient is conscious coherent but not cooperative well oriented to
time place and person. He is moderately built and nourished
Pallor absent
Icterus absent
Cyanosis absent
Clubbing absent
Edema absent
Lymphadenopathy absent
Vitals
Temp afebrile
PR 82bpm
RR 18 cpm
GRBS
10am- 377mg/dl 6ml/hr
2pm- 152mg/dl 2ml/hr
6pm-170mg/dl 2ml/hr
8pm- 96mg/dl 2ml/hr
2am 84mg/dl
SYSTEMIC EXAMINATION
CVS-s1s2 +
Pa-soft and non tender
Rs-BAE+
Investigation
HEMOGRAM
24/8/2022
HB-15.8
TLC-13200
PCV-44.7
MCV-88
MCH-31.1
MCHC-35.3
PLATELETS- 1.64
RBC-5.08
25/8/2022
HB-14.4
TLC-11000
PCV-40.7
MCV-89.3
MCH-31.6
MCHC-35.4
PLATELETS- 3.70
RBC-4.56
26/8/2022
HB-14.7
TLC-8900
PCV-42.8
MCV-91.5
MCH-31.4
MCHC-34.3
PLATELETS- 3.51
RBC-4.68
27/8/2022
HB-14.4
TLC-7300
PCV-41.2
MCV-90.9
MCH-31.6
MCHC-34.8
PLATELETS-3.45
RBC-4.54
ECG-NORMAL SINUS RHYTHM
MRI BRAIN-(24/8/2022)
POSTERIOR PREDOMINANT SUBCORTICAL FLAIR HYPOINTENSITY AND CORTICAL(GYRAL)
HYPERINTENSITY IN BILATERAL CEREBRAL HEMISPHERES, MORE ON LEFT SIDE
F/S/O HYPERGLYCEMIA INDUCED SEIZURES/NON KETOTIC HYPERGLYCEMIA
BILATERAL SYMMETRICAL PERIVENTRICULAR HYPERINTENSITIES-CHRONIC SMALL
VESSEL ISCHEMIA
USG-NO SONOLOGICAL ABNORMALITY DETECTED
FUNDOSCOPY-MILD TO MODERATE CHANGES OF HYPERTENSIVE RTINOPATHY NOTED
Treatment Given (Enter only Generic Name)
1) inj HAI 1ml (400)+39 ml NS2)inj levipil 500mg iv bd3)inj thiamine 200mg in 100ml NS iv TID4) inj zofer 4mg/iv/sos5) inj pan 40 mg iv OD6) BP/pr/rr/spo2 charting 2nd hourly8) tab atorvas 20 mg Po OD
Page-5
KIMS HOSPITALS
Advice at Discharge
1)TAB LEVIPIL 500MG PO BD
2)TAB TELMA 40MG PO OD
3)INJ HAI 6U SC TID
4 INJ NPH 6 UNITS SC BD
4)STRICT DIABETIC DIET AND SALT RESTRICTION
Follow Up
REVIEW SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendant Declaration: - The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date: 27/8/2022Ward: Unit:2
[4:19 pm, 14/01/2026] PPM 1: His creatinine was 1.4-2.0 during his first admission in 2022 and gradually progressed till 2026 to 11 and he came to us recently with shortness of breath suggestive of pulmonary edema
[4:17 pm, 14/01/2026] PPM 1: @PPM4 please share his deidentified chest X-ray and ECG
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