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.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
A 42yr old Male with chiefcomplaints of vomitings and breathlessness
B.Gayathri
Roll No: 22
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.
CASE:
40year old male presented with chief complaints of vomitings and breathlesness on 26/12/22 (since 3 days) .
HISTORY OF PRESENTING ILLNESS:
Patient was apparrently asymptomatic 3 days ago with a background alcoholic intake without having food.Then he had complaints of vomiting for 3 days ,non bilious ,food as content, non foul smelling.Patinet had taken vomikind injection.From then patient has the history of feeling breathlessness since yesterday (26/12/22).Then patient went for consultation in governtment hospital and was referred to higher centre for which he came to our hospital.
PAST HISTORY:
He was a known case of diabetes since 7 years and was on oral hypoglycemic drugs - Glybenclamide and metformin
(Irregular medication).He is not taking tablets since 1 week as they are not available.
Not a known case of hypertension,asthma,tuberculosis ,epilpsy,coronary artery diseases.
DAILY ROUTINE:
He is a resindent of nagarjuna sagar He owns a car works as car driver.He wakes up early morning at 6 '0 clock ,does his morning routine and eats breakfast at 8:30 am .Then he goes to work at 9 '0 clock and has his lunch around 1-2 pm returns home by 8pm and does his dinner chapathi with curry daily by 9pm and sleeps at 10pm.
PERSONAL HISTORY:
Diet: Mixed
Appetite: Normal
Bowel and bladder: Regular
Sleep:Adequate
Addictions:Occasional alcoholic since 15 years .
No allergies .
FAMILY HISTORY:
No significant family history.
GENERAL EXAMINATION:
Patient is conscious, cohorent,cooperative and well oriented to time, place and person.
Hyperpigmented lesions noted over both upper and lower limbs.
Icterus- absent
Clubbing-absent
Lymphadenopathy- absent
Cyanosis- absent
Generalized edema - absent
VITALS:
B.P:150/80 mmhg
P.R:110bpm
R.R: 42cpm
Temp:98.6 F
SPO2: 99%@ RA
SYSTEMIC EXAMINATION:
ABDOMEN EXAMINATION:
Inspection -
Umbilicus - inverted
All quadrants moving equally with respiration
No scars, sinuses and engorged veins , visible pulsations.
Palpation -
soft, non-tender
no palpable spleen and liver
Percussion - resonant note is heard
Auscultation- normal bowel sounds heard.
CARDIOVASCULAR SYSTEM:
Inspection :
- Shape of chest- elliptical
- No engorged veins, scars, visible pulsations
- JVP - no raised jvp
Palpation :
- Apex beat can be palpable in 5th inter costal space
- No thrills and parasternal heaves can be felt
Auscultation :
- S1,S2 are heard
- no murmurs
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion: resonant bilaterally
Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard.
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
PROVISIONAL DIAGNOSIS:
Diabetic ketoacidosis secondary to in compliance with known case of type2 Diabetes mellitus with pseudohyponatrmemia.
Investigations:
TREATMENT:
Comments
Post a Comment