38 y/o male suffering with SOB

 Note : This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence based inputs.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. 

I have been given the following case to solve, in an attempt to understand  the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings,  Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

Name : M.Aishwarya

Roll No : 89

Case Scenario : A 35 year old male who's a construction worker by profession has complaints of :

  • Vomitings since 1 day
  • Pain abdomen since 1 day
  • Shortness of breath since 1 day
History of Present Illness :
  • Patient had complaints of vomiting from the afternoon of day before admission. About 4-5 episodes, watery in nature, not tinged with blood.
  • As a result, patient hasn't consumed any food since.
  • Patient complains of pain of lower abdomen. Insidious in onset, no progression or radiation, intermittent and stabbing type of pain.
  • So he was taken to a nearby RMP where his sugar levels were diagnosed to be about 580 mg/dL, hence he was given medication for that.
  • In morning, patient started to experience shortness of breath and labored breathing, for which he was admitted into the ICU ward.
History of Past Illness : 
  • Patient diagnosed with Diabetes Mellitus Type - 2 about 2-3 years ago.
  • He was apparently regular with his medication, until 4 days ago.
Personal History :
  • Marital status - Married
  • Occupation - Construction worker
  • Appetite - Reduced
  • Diet - Mixed
  • Bowel movements - Reduced 
  • Micturition - Regular
  • Sleep - Regular 
  • Known allergies - None
  • Habits/addictions - Consumption of  Beer, Toddy, Beedi smoking.
  • Beer - occasional, last consumed 4 days back.
  • Toddy - 1 litre/week, since childhood 
  • Known alcoholic since 10 years, consumes a quarter frequently. 
Family History :  Father has history of alcoholism and Type-1 DM and an episode of stroke induced paralysis

Treatment History:
Taking medication for Type - 1 DM since past 2-3 years.

PHYSICAL EXAMINATION

A. General
  • Pallor - No
  • Icterus - No
  • Cyanosis - No
  • Clubbing of toes/fingers - No
  • Lymphadenopathy - No
  • Oedema of feet - No
  • Malnutrition - No
  • Dehydration - No
  • Pulse rate - 111 beats/min
  • Respiratory rate - 40 breaths/min
  • Blood pressure -  110/70 mmHg
  • SpO2 at room air -95 %
  • GRBS -519 mg%
  • No birth deformities seen
B. Cardiovascular system

  • Thrills - No
  • Cardiac sounds - S1,S2
  • Cardiac murmurs - none
C. Respiratory system
  • Dyspnoea - No
  • Wheeze - No
  • Position of trachea - General
  • Respiratory sounds - Vestibular
  • No abnormal sounds detected
D. Abdomen
  • Shape of abdomen - Scaphoid
  • Tenderness - None 
  • Palpable mass - None
  • Hernial orifices - None
  • Free fluid - None
  • Bruits - None
  • Bowel sounds - None
  • Spleen and Liver - Not palpable
E. CNS
  • Patient is conscious, coherent with normal speech
  • No signs of meningeal irritation
  • Normal sensory system, motor system, cranial nerve functioning observed.
  • Normal reflexes, cerebellar functioning and gait seen.
PROVISIONAL DIAGNOSIS : Diabetic Ketoacidosis

Treatment :

Day 1

  • IV fluids NS continuous 125 mL/hr
  • Inj. HAI - 6 mL/hr
  • Inj.ZOFER - 4 mg/IV/BD
  • Inj.PAN - 40 mg/IV/BBF
  • Hourly GRBS monitoring
  • Vitals monitoring
Day 2

  • IV Fluids - NS, RL, 5% Dextrose - 100 ml/hr
  • Inj.HAI - 6 mL/hr
  • Inj.PAN - 40 mg/IV/BBF
  • Inj.ZOFER - 4 mg/IV/SOS
  • Hourly GRBS monitoring
  • Vitals monitoring 

Investigations : 
                            
                                        ECG



Blood sugar


Hemogram



Urine exam



LFT


RFT



Blood Urea



Serum Creatinine 


HIV Rapid test






HBsAg



Vitals Chart








































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