Tondapu Sreelekha, 8th semester
Roll no. – 135
This is online E log book to discuss our patient’s de-identified
health data shared after taking his/her/guardian’s signed informed consent.
Here we discuss our individual patient’s 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 centred
online learning portfolio and your valuable inputs on comment box is welcome
I’ve 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.
Following is the view of my case: (history as per date of admission)
CASE
A 38-year-old male came to the OPD with chief complaints of shortness of breath since 4 days, right ear pain since 5 days, bilateral leg pain since 1 month, vomiting since 10 months.
HISTORY OF PRESENTING ILLNESS
Patient was
apparently asymptomatic 10 months back when he had episodes of vomiting which
were ON and OFF.
Later he developed
bilateral leg pain 1 month back.
He had had right
ear pain for 5 days which was associated with ear discharge which was mucoid,
blood stained, non foul smelling. There is no history of trauma, URTI,
decreased hearing, giddiness.
He developed
shortness of breath 4 days back.
PAST HISTORY
· No similar complaints in the past.
· He is a known case of diabetes mellitus
since 1 year for which he used medication for 10 months, after which he stopped
taking medication on his own and started using ayurvedic medication.
· He is not a known case of hypertension,
TB, Asthma and epilepsy
PERSONAL HISTORY
· DIET- Mixed
· APPETITE- normal
· SLEEP- Adequate
· BOWELS- Regular
· MICTURATION- Normal
· ADDICTIONS- None
· ALLERGIES- None
FAMILY HISTORY
· There is no
significant family history.
GENERAL EXAMINATION
The patient was drowsy and had altered sensorium.
He was moderately built and moderately nourished.
· No pallor
· No icterus
· No cyanosis
· No clubbing
· No generalized
lymphadenopathy
· No pedal oedema
VITALS at the time of admission
·
Temperature:
98.4F
·
Pulse:
94 beats/mins
·
Blood
pressure: 110/70 mmHg
·
Respiratory
rate: 24 cycles/min
·
GRBS:
175mg/dL
SYSEMIC EXAMINATION
CVS
· S1 and S2 heart
sounds heard.
· No murmurs heard.
Respiratory system
· Bilateral air entry +
· No crepts
CNS
Altered sensorium
Abdomen
· Soft and non-tender.
· Bowel sounds were
heard.
· No organomegaly.
INVESTIGATIONS
LFT
· Total bilirubin: 1.0
mg/dl
· Direct bilirubin: 0.2
mg/dl
· SGOT: 26 IU/L
· SGPT: 12 IU/ L
· ALP: 222 IU/L
· Total proteins: 7.1
gm/dl
· Albumin: 3.8gm/dl
· A/G ratio: 1.16
RFT
· Blood urea : 39 mg/dl
· Serum creatinine : 0.6
mg/dl
· Uric acid: 6.7 mg/dl
· Calcium : 10 mg/dl
· Phosphorus : 2.1
mg/dl
· Sodium : 130 mEq/L
· Potassium : 3.8 mEq/L
Chloride :
98mEq/L
Haemoglobin: 16.2gm/dl
TLC: 7,700
Urine analysis
·
Ketones: positive
·
Albumin: positive
·
Sugar: 3+
·
Pus cells: 3-4
·
Epithelial cells: 2 to 4
Provisional diagnosis: Diabetic ketoacidosis secondary to non compliance to
insulin. Pseudo hyponatremia secondary to hyperglycemia.
Treatment given:
·
IVF NS @ 100ml/hr
·
IVF FUSIDEX @ 75ml/hr if GRBS is less than
200mg/ dl
·
Inj. 40IU
HAI in 39ml NS @ 5ml/hr algorithm 2 to be followed.
·
NBM till further orders.
·
Inj. NaHCO3 50mEq IV stat followed by Inj.
NaHCO3 100mEq I 200ml NS stat.
·
GRBS 6th hourly charting.
·
Temperature 4 hourly charting
·
Strict I/O charting
·
BP/ PR/ spO2 charting 2 hourly
·
Inj. ZOSTOM 1.5gm/IV/BD
·
Tab. CLOWAZEPAM 0.5mg/PO/Stat
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