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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 14-2-23 (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.Patient had taken vomikind injection. patient has the history of feeling breathlessness since 3 days of vomiting(11-2-23).
Then patient went for consultation in governtment hospital and was referred to higher centre for which he came to our hospital.
PAST HISTORY:
No similar complaints in the past
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 for food or drugs.
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
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 Type 2Diabetes milletus
Investigations:
Hb: 4.6 g/dl
Sr.creat:4.2
Blood urea :90
HBA1C:7.5
FBS 304mg/dl
TGL:182
HDL 56
LDL 115
VLDL 36
ABG ANALYSIS
pH 7.332
pco2 47.5 mmHg
po2 90.4mmHg
Electrolytes
Na-136mmol/l
K+- 3.5 mmol/l
Cl-96mmol/l
Hco3- 13.6 mmol/l
Urine ketones -positive
TREATMENT:
On 14-2-23
Inj human act rapid insulin 0.1 IU/kg/hr
Continue iv infusion
Inj PAN 40 mg /IV/OD
Inj Thiamine 200 mg /100 ml NS IV/BD
Inj monocef 1gm/IV /BD
Serum potassium every 6 hrly
Vitals monitoring every 4 hrly and GRBS hrly monitoring
Inj 10%dextrose 30 ml/hr/IV
On 15-2-23
Same plus GRBS and vitals monitoring
On 16-2-23
GRBS And vitals monitoring .
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