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

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