1601006086 short case

This is an 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 patient's clinical problems with collective current best evidence based on inputs

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 a diagnosis and treatment plan. 

34 y/m labourer by occupation came with a chief complaints of fever since 10 days

 cough since 7 days 

sob since 4 days

History of present illness:

Pt was apparently asymptomatic 1 month back then develped SOB which is gr 2 and generalised weakness which is a/w fever (low grade,non continous ,not a/w chills and rigor no diurnal variation )

cough a/w sputum -whitish purulent moderate amounts since 7 days.


SOB gradually progressed from  grade 2 to 4 a/w chest tightness and difficulty in breathing no c/o palpitation and syncope attacks 

no c/o burning micturition loose stools and constipation 

H/o nausea and vomitings 

Polyphagia  since 2 months 

Polyuria since 2months

Past history:

no h/o DM , HTN ,CVA ,CAD, TB ,EPILEPSY .

not significant

personal history

diet:vegeterian

appetite :decreased

bowel and bladder;normal

addictions ;180-360 ml/day since 14 years

                   16-18 beedis/day

sleep disturbed

 family history: no relevant history

General examination:

Patient is conscious coherant and cooperative 

ILL built and nourished

No signs of pallor 

                  Icterus 

                   Clubbing

                   Kolionychia

                    Lymphadenopathy

                    Edema

Vital signs :

Blood pressure : 90/60 mm                     

Pulse rate : 100 per min regular 

Respiratory rate - 24 cycles /min

Spo2- 98%

Afebrile 


Respiratory system examination:

Decreased breath sounds 

Bilateral IAA,ISA

Auscultation:

Bilateral air entry - present

Decreased air entry on left mammary area

And in Infraaxiallary area, infra  scapulary area

Wheeze and coarse crepts present


Cardiovascular system examination:

S1 and S2 present


Central nervous system examination:NAD

Investigations:

Routine investigations:



Bilateral grade 1 RPD 

Chronic  pancreatitis

Minimal ascites

provisional diagnosis:

DKA with consolidation in left lung


Treatment 

IVF -- NS and RL  100ml / hr continuos

Inj pantoo 40mg /IV /OD

Inj augmentin 1.2gm/IV /BD

Tab dolo 650 mg/PO

Syp- ascoryl -p 10 ml/Po /tid

10ml -10ml - 10ml

GRBS charting 2nd hrly

Inj kcl 2 ampoules 

In 10 NS 

Over 4-5 hours

Comments

Post a Comment

Popular posts from this blog

42 year old women with multiple health events

Image
I have given this case to solve and understand about " Patient clinical analysis " With given history and provided clinical investigations.  Clinical problems in patient: Migraine Kidney dysfunction - oligouria Swelling Sleep disturbances Left hand numbness Poor vision Broken leg Autism Intolerance to some kind of food Reasons for problems: From given data it could be from G 6 PD deficiency and AMPD 1 deficiency Sleep deprivation is due reduce synthesis of amino acids like adenosine defiency which is inhibitory to brain.  Kidney dysfunction is due to decrease in atp synthesis which also explains increase in intake of salt Swelling is due to g6pd defiency Others symtoms are due to genetic abnormalties like: Seattle type G6PD deficiency AMPD1 - AMPD1 deficiency heterozygous MTHFR - homozygous for C677T of MTHFR = 10-20% efficiency in processing folic acid = high homocysteine, low B12 and folate levels WNK1 mutation HLA-DRA - 3x higher risk for developing a peanut allergy In pop
Read more

16010086 long case

Image
This is an 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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment 29 year old male who is a daily wage labourer resident of Nalgonda, came to hospital with   chief complaints on & off fever since 2 yrs , shortness of breath , b/l pedal edema , abdominal distension and decreased urine output since 1 year History of present illness : Patient was apparently asymptomatic 2years ago and then one day he developed  fever  (high grade , continuous , associated with chills & rigors) and  generalized body aches  for which he went to a local RMP and he pr
Read more

56 year old male

A 56yr old male came to casuality with  chief  complaints of  pain abdomen since 5 days polyuria since 5 days  Dyspepsia since 2 days  History of present illness:  patient was apparently asymptomatic 5 days back,then he developed pain in the abdomen (Epigastric region) non radiating,not associated with nausea,vomitings(burning type of pain) decreased on using medication  H/o alcohol binge 5 days back,then developed pain abdomen ( diffuse type, squeezinf type of pain) not associated with nausea,vomitings)  went to a local RMP and diagonsed with Diabetes mellitus (DE NOVO) and was started on (T.GLIBENCLAMIDE and METFORMIN)/PO/OD No H/O burning micturition,fever,cough,cold,SOB,tingling sensation of B/L UL and LL,loose stools and chest pain Past History : H/O simliar complaints in the past diagnosed as pancreatitis  not a K/c/o DM,HTN  k/c/o Alcoholic since 30 yrs  last intake (3-5 days back) he is a smoker ( stopped 8 years back ) Personal history: mixed diet normal appetite bowel regular
Read more