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 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.


A 50 year old male is presented to OPD with chief complaints of altered sensorium, fever and  vomitings since 5 days.


HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 10 years back then he developed giddiness on routine check up and was diagnosed with diabetes.

Patient had 4 months back injury to left foot with small ulcer which progressed and amputation of last 3 toes of the foot.

5 days back he went to brother's home as there was a party, he had mutton curry he skipped taking medication then behaviour of patient was abnormal and had a episode of vomiting which is non bilious and non projectile

And since 15 yrs patient is on medication 


HISTORY OF PAST ILLNESS-:

Patient is Diabetic since 10 years

No history of hypertension, tuberculosis, epilepsy

Patient has no history of drug allergies


PERSONAL HISTORY-:

Diet-mixed

Appetite-lost

Bowel and bladder movement-normal

 Micrurition-normal

Sleep-inadequate 

Alcohol- occasionally


FAMILY HISTORY-:

No member in the family has similar complaints.


TREATMENT HISTORY-:

Patient has history of amputation of last three toes of left foot.


GENERAL EXAMINATION-:

Patient is conscious,coherent and cooperative.

There is sign of pallor

There is mild dehydration 

There is no sign of icterus, cyanosis, clubbing, generalised  lymphadenopathy









VITALS :

Temp :febrile 


Pulse rate:91bpm


Respiratory rate:24cpm


Bp:220/100 mm/hg


Spo2-97%


GRBS-524mg/dl


SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM

Inspection: 

Chest wall is bilaterally symmetrical

No Precordial bulge


No visible pulsations, engorged veins,scars, sinuses


Palpation:

JVP - normal

Apex beat : felt in the left 5th intercostal space

In midclavicular line 


Ausculation:

S1 ,S2 Heard



RESPIRATORY SYSTEM

Bilateral airway +

Position of trachea- central

Normal vesicular breaths heard

No added sounds


PER ABDOMEN

Abdomen is soft and non tender 


Bowel sounds heard


No palpable mass or free fluid 



CENTRAL NERVOUS SYSTEM

Patient is conscious 


Reflexes are normal 


Speech is normal


Provisional diagnosis-:

Diabetic ketoacidosis 


INVESTIGATION-:



Treatment 














Comments

Post a Comment

Popular posts from this blog

Case-1

Image
 Aug 9,2021 Date of Admission-31-7-21 A 60 year old female presented to OPD with chief complaints of diffuse abdominal pain since 7-10days HISTORY OF PRESENT ILLNESS Patient was diagnosed in the nearest hospital 1 year back due to bloating of stomach. The Patient didn't undergo for the further treatment at that time. Patient was suffering from abdominal pain since a month ago and went to the nearest hospital. Test were performed and the reports shown that she is hypoglycemic, hyponatremic and CRP was extremely high about 92.7mh/l and serum creatinine level was 8.9mg/dl. She was refered then to KIMS for further treatment. She is undergoing dialysis(4) since then  She complains of hard stool and prescribed with liq paraffin and milk of magnesia syrup 10ml 3 times a day. She was hypovolemic and undergone blood infusion of 1 unit ( Blood group- B+) HISTORY OF PAST ILLNESS  No history of surgery, asthma, TB, CAD, epilepsy. PERSONAL HISTORY Decrease appetite  Bowel movement is irregular
Read more

Case 6

Image
 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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. A 50 year old man presented to OPD with chief complaints of shortness of breath since 3 days. face puffiness,decreased urine output and pedal edema since 3 months. HISTORY OF PRESENT ILLNESS  Patient was apparently alright 3 months back then he developed bilateral pedal edema which is pitting type. No history of chest pain, blurring of vision, loose stool, vomiting, cough, abdominal distinction. HISTORY OF PAST ILLNESS  No history of diabetes, asthma, CAD, hypertension, tuberculosis, previous surgery  PERSONAL HISTORY  Diet-Mixed Appetite-Normal Bowels-regular Sleep-normal FAMILY HISTORY  No history of hype
Read more