GENERAL MEDICINE E-log

NAME: A Sanvith

Roll No: 09 

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 SOS

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