Hi, I am D.Vasista Pranav 5th semester medical student. This is an online e log of patient's de-identified health data shared after taking his/her/guardian's 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.This e-log also reflects my patient centered online learning portfolio
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan
CHIEF COMPLAINTS:
A 54 year old male, resident of Yadadri, came with complaints of:
* Fever since 3am in the morning.
* Vomiting since 3am in the morning.
* Troat pain since 7am in the morning.
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 1 month back, then he developed generalised itching of body and then went to RMP, where he advised to stop the night dosage of insulin.
After following the advise, the itching did not reduce, so the patient stopped the morning dosage of insulin without authorised advice from a doctor.
He continued taking the afternoon dosage of Tab.Metformin 500mg PO/OD.
Now, since morning, he developed low grade fever, that was insidious in onset, gradually progressing, not associated with chills or rigor. There were no aggravating or reducing factors.
The fever was followed by 3 episodes of vomiting since 3am in the morning, with previous nights food as contents, non-bilious, non-blood stained, non-projectile, associated with generalised weakness.
He also complaints of mild throat pain after vomiting, since 4am this morning, not associated with aggravating or relieving factors.
No H/O headaches, vision changes, dizziness, seizures.
No H/O SOB, cold, cough, chest pain, palpitations, orthopnea, PND.
No H/O loose stools, burning micturition.
No H/O abdominal pain.
PAST HISTORY:
Daily routine:
The patient works as a construction worker in Yadadri district.
He wakes up at 5:30am everyday and visits his fields around 7am. He returns from the fields around 8am, has some rice for breakfast and takes his insulin shot.
He goes to work and comes back around 1pm for lunch, after which he goes back to work and returns in the evening at about 6pm. He has his dinner by 8pm, takes his insulin shot and sleeps by 10pm.
His routine hasn’t changed in the last day.
The patient is a K/C/O Type II DM, since 4 years.
* There is no H/O similar complaints in the past.
* Not a K/C/O HTN, TB, Asthma, Epilepsy, CVA, CAD.
* No H/O surgeries in the past.
PERSONAL HISTORY:
* Diet - Mixed
* Appetite - Normal
* Sleep - Normal
* Bowel and Bladder - Normal urination, normal bowel.
* Allergy - None
* Addictions
- Alcohol - about 90ml daily ,since his 20 years.
Last intake about 1 week ago.
FAMILY HISTORY:
No history of similar complaints in the family.
GENERAL EXAMINATION:
The patient is conscious,coherent and cooperative; well oriented to time,place and person.
He is sleeping comfortably on the bed.
He is thinly build and well nourished.
* Pallor - present
*Icterus- absent
*Clubbing-absent
*Cyanosis-absent
*Lymphadenopathy-absent
*Edema - absent
Vitals at the time of admission:
*Temperature - 98.6 F.
*Pulse rate - 140/ minute
*Respiratory rate - 22/minute
*Blood pressure (left arm) - 90/60 mm of Hg
*GRBS - 515mg/dl
CVS:
S1 and S2 heard.
No addded thrills or murmurs heard
RESPIRATORY SYSTEM:
Normal vesicular breath sounds heard.
Bilateral air entry present.
ABDOMEN:
non tender
soft
CNS:
Conscious and coherent.
Normal sensory and motor responses.
INVESTIGATIONS :
ECG-
Chest X-Ray-
PROVISIONAL DIAGNOSIS:
The patient is suffering from uncontrolled sugars ?DKA ?HHS with pyrexia ?viral, with K/C/O DM II since
TREATMENT:
21/07/2023:
1.
IV fluids - NS 2 . Bolus at 100ml/hour
↓
Inj. HAI 6units IV stat.
↓
Inj. HAI 6 units IV stat.
↓
Inj. HAI 1ml in 39ml NS, at 6ml/hour.
(Increase according to GRBS)
2. Monitor GRBS hourly.
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