GENERAL MEDICINE E-LOG

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

Date of admission: 8/06/22 

CHIEF COMPLAINT: 

- A patient aged 28 years was brought to the casuality with chief complaints of 

• Giddiness 
• Headache 
• Decreased responsiveness 

- Patient had a history of ratpoison consumption 4 days back and got discharged after being treated. 

HISTORY OF PRESENT ILLNESS: 

           

     Patient was apparently asymptomatic 1 week back and then she had consumed rat poison which caused zinc phospide poisoning on 3rd June 2022 and the patient was treated conservatively and got discharged on 6th June.

     On 8th June patient visited the hospital with complaints of decreased appetite and 1 episode of fever not associated with chills and also had complaints of difficulty in speech and altered behavior.

     No history of seizures and vomiting, abdominal pain and distension, pedal edema.

HISTORY OF PAST ILLNESS: 

  

     Not a k/c/o DM,HTN, coronary artery disease, asthma, TB 

TREATMENT HISTORY: 

    No significant treatment history 

PERSONAL HISTORY: 

• Appetite is normal 
• Having mixed diet( Non vegetarian) 
• Bowels- regular
• Micturition- normal
• No history of Alcohol intake
• No history of smoking 
• No other habits/ addictions 

GENERAL EXAMINATION:

Patient is conscious.

Pallor is present.

Absence of Icterus, Clubbing, Cyanosis, Pedal edema, Lymphadenopathy.

VITALS:

1.Temperature: 98.4F

2.Pulse rate: 112 beats per min

3.Respiratory rate: 30 cycles per min 

4.BP: 120/80mm Hg

5.SpO2: 96%@Room air 

6.GRBS: 118mg% 

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

• S1, S2 heard
• No thrills, No murmurs

RESPIRATORY SYSTEM:

• Normal vesicular breath sounds
• Position of trachea is central
• Dyspnea is present
• No wheeze

EXAMINATION OF ABDOMEN:

• Shape- scaphoid
• No tenderness
• No palpable pass
• Normal hernial orifices 
• No free fluid
• No Bruits
• Liver is not palpable
• spleen is not palpable
• Bowel sounds heard

CENTRAL NERVOUS SYSTEM:

• Patient is conscious 
• Speech is normal 
• No focal neurological defect
• Cerebral signs- unable to examine as the patient was drowsy. 

PROVISIONAL DIAGNOSIS:

   ZINC PHOSPHIDE POISONING 

INVESTIGATIONS: 

 

TREATMENT:

TREATMENT ON 8/06/22: 

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

TREATMENT ON 9-06-22:

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 SOS

TREATMENT ON 10-06-22: 

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 SOS