DKA with left lung upper lobe consolidation
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"
GENERAL MEDICINE CASE FINAL PRACTICAL EXAM LONG 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.
34 y/m labourer by occupation came with a chief complaint 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 f/b 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 2 to 4 a?w chest tightness and difficulty in breathing no c/o palpitation and syncope attacks
no c/o burning micturition lo sadose stools and constipation
nausea and vomitings
Polyphasia since 2 months
Polyddipsia since 2 months
Polyuria since 2months
Pastt history:
no h/o DM HTN CVA CAD TB EPILEPSY
not significant
personal history
diet:vegeterian
apetite: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 hg kiThis 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"
April 25, 2021
GENERAL MEDICINE CASE FINAL PRACTICAL EXAM LONG 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 inputs.
This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the 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 a diagnosis and treatment plan. CC:
34 y/m labourer by occupation came with a chief complaint 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 f/b 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 2 to 4 a?w chest tightness and difficulty in breathing no c/o palpitation and syncope attacks
no c/o burning micturition lo sadose stools and constipation
nausea and vomitings
Polyphasia since 2 months
Polyddipsia since 2 months
Polyuria since 2 months
Pastt history:
no h/o DM HTN CVA CAD TB EPILEPSY
not significant
personal history
Chronic smoker
1 beedi packet /day
Chronic alcoholic 90ml/day
Stopped 2 months back
diet:vegeterian
apetite: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 hg
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, intra scapulary area
Wheeze and coarse crepts present
Cardiovascular system examination:
S1 and S2 present
Central nervous system examination:NAD
Investigations:
Routine investigations:
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, intra scapulary area
Wheeze and coarse crepts present
Cardiovascular system examination:
S1 and S2 present
Central nervous system examination:NAD
Investigations:
Routine investigations:
Chest X Ray
Ultrasound findings
Bilateral grade 1 RPD
Chronic cacific pancreatitis
Minimal ascites
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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