𝗔 𝟳𝟱 𝘆𝗲𝗮𝗿 𝗼𝗹𝗱 𝘄𝗼𝗺𝗮𝗻 𝘄𝗶𝘁𝗵 𝗮𝗹𝘁𝗲𝗿𝗲𝗱 𝘀𝗲𝗻𝘀𝗼𝗿𝗶𝘂𝗺....

THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. THIS E LOG ALSO REFLECTS MY PATIENT-CENTERED ONLINE LEARNING PORTFOLIO AND YOUR VALUABLE INPUTS IN THE COMMENT BOX ARE WELCOME.

𝐀 𝟕𝟓 𝐲𝐞𝐚𝐫 𝐨𝐥𝐝 𝐰𝐨𝐦𝐚𝐧 𝐰𝐚𝐬 𝐛𝐫𝐨𝐮𝐠𝐡𝐭 𝐭𝐨 𝐜𝐚𝐬𝐮𝐚𝐥𝐢𝐭𝐲 𝐰𝐢𝐭𝐡

CHIEF COMPLAINTS

Drowsiness since yesterday 3pm.

HOPI

The patient was apparently asymptomatic until 3pm yesterday after which she started feeling drowsy and sleepy. She took 2 zantac tablets yesterday because she was feeling Burning sensation in the chest.

No H/O altered behaviour, agitation, irrelevant talk, screaming.

No H/O fever, neck stiffness.

PAST HISTORY

No H/O similar illness in the past.

N/K/C/O HTN, DM, CAD, TB, asthma, epilepsy, thyroid disorders.

H/O cataract surgery.

PERSONAL HISTORY

Diet: Mixed

Appetite: Normal

Sleep: Adequate

Bowel and Bladder movements are Regular

No allergies

Addictions: she consumes toddy daily (500-750ml)

H/O tobacco chewing

FAMILY HISTORY

Insignificant

MENSTRUAL HISTORY

Attained menopause

DAILY ROUTINE

The patient wakes up at 6.30am in the morning, does household work, and eats breakfast (rice and curry) at 9am. After having breakfast, she chitchats with the neighbors and plays pachisi with them. She will eat lunch (rice and curry) at 1pm and sleep for a while. She drinks toddy in the evening at around 5pm, cooks food, has dinner (rice and curry) by 7pm, and goes to bed by 8pm.

EVENTS ON THE DAY OF INCIDENT

She woke up at 6.30am, did the household work, and ate breakfast (rice and chicken curry) at 9am. After having food, she felt some burning sensation in her chest, so she took a Zantac tab, but that didn't make her feel better, so she took another tab. She skipped her lunch because she was not feeling hungry. At around 3pm she was feeling drowsy and slept. Her family members came home from work at 5pm and found her sleeping. They woke her up; she had slurred speech. They waited till 6.30pm thinking that she might come back to her normal state, but she hasn't, so they brought her to the casualty.

EXAMINATION

Temp: Afebrile

Pulse: 88bpm

RR: 16cpm

BP: 90/60 mm of Hg

Spo2: 97

CLINICAL IMAGES