A 60 YEAR OLD MALE WITH FEVER AND DIFFICULTY IN SWALLOWING

 Under the guidance of  INTERN PRAKASH SIR


This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent.
 Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case 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.

CASE SCENARIO

A 60 year old male, daily wage labour  came to casualty with complaints of fever since 3days,nausea and vomiting from yesterday, difficulty in swallowing from yesterday and giddiness from yesterday.

HISTORY OF PRESENT ILLNESS
patient apparently asymptomatic 5days back,
then he complaints of polyuria and nocturia   Since 5days.
patient complaints of high grade fever since 3days. Which is continuos associated with chills and rigors.
patient complaints of cold and cough associated with sputum, which is mucoid,greenish,non blood stained since 3days.
complaints of nausea and vomiting yesterday, which is 3to4 episodes and associated with food particles, non bilious, not associated with blood.
complaints of  giddiness from yesterday.

No c/o chest pain, palpitation, syncopal attacks, burning micturition.

No c/o SOB, orthopnea

K/c/o of type 2 DM from 12years and he is on Human mixtard 25U(8am)and28U(8pm)

No h/o HTN,CVA,CAD,TB, Epilepsy

No c/o pedal edema, facial puffiness.


O/E
Patient was C/C/C, moderately, built and nourished.
No pallor, icterus, cyanosis, clubbing, pedal edema, lymphadenopathy.

VITALS
Temp:100.8F
Bp:90/60
PR:82bpm
RR:18
Spo2:99 at room air
GRBS: HI
CVS- s1s2 heard
RS: BAE+
P/a: soft,non tender and bowel sounds are heard.
 

CNS - HMF intact
Reflexes-
                    B   T   S    K    A 
RL:.              +    +    +   +    +
LL:.               +     +    +   +  +
Plantars : Rt - withdrawal
                  Lt - withdrawal

Tone:  Rt .UL :Normal
             Lf. UL: Normal
             Rt. LL : Normal
             Lf. LL: Normal

  Power: Rt .UL: Normal
             Lf. UL: Normal
             Rt. LL: Normal
             Lf. LL: Normal


Provisional diagnosis: Diabetic ketoacidosis with type2 diabetes since 12years


INVESTIGATIONS: 

ON DAY 1 :


CUE


SERUM ELECTROLYTES




SERUM CREATININE




BLOOD UREA


HEMOGRAM


LIVER FUNCTION TEST









ON DAY 2 :















ON DAY 3 :












TREATMENT :

ON DAY 1 :
 
1. IVF NS 125 ml/hr
2. Inj. HAI 6U IV/STAT
3.Inj. HAI - IV infusion [ 1ml in 39ml NS]
4. Inj.PAN 40mg IV/OD
5.Inj. Zofer 4mg IV/TID
6.Tab.PCM 650 PO/SOS
7.Inj.Neomol IV/SOS
8.SYP. Ambroxol 5ml/PO/TID
9.Tab. Citrizine 5mg/PO/BD
10.GRBS Charting hourly
11. BP/PP/RR/SPO2 charting 4th hourly

ON DAY 2 :

O/E 
Patient is c/c/c 
temperature: afebrile
BP : 110/80 mm Hg
PP : 92 bpm , regular
CVS : S1 , S2 present
RS : BAE present
P/A : soft non tender


1. IVF NS @100ml/ hr
2. Inj. HAI SC/TID
3. Inj.PAN 40mg IV/OD
4.Inj. Zofer 4mg IV/TID
5.Tab.PCM 650 PO/SOS
6.Inj.Neomol IV/SOS
7.SYP. Ambroxol 5ml/PO/TID
8.Tab. Citrizine 5mg/PO/BD
9.GRBS Charting 2nd hourly
10. BP/PP/RR/SPO2 charting 4th hourly

 ON DAY 3

Diagnosis : DIABETIC KETOACICOSIS [RESOLVED]

No c/o : fever spikes , cold subsided

O/E 
Patient is c/c/c 
temperature: afebrile
BP : 120/80 mm Hg
PP : 70 bpm , regular
CVS : S1 , S2 present
RS : BAE present
P/A : soft non tender

1. IVF NS @100ml/ hr
2. Inj. NPH SC/BD, HAI SC/TID
3. Inj.PAN 40mg IV/OD
4.Inj. Zofer 4mg IV/TID
5.Tab.PCM 650 PO/SOS
6.SYP.Cremaffin 15ml PO/SOS
7.SYP. Ambroxol 5ml/PO/SOS
8.Tab. Citrizine 5mg/PO/OD
9.GRBS Charting
10. BP/PP/RR/SPO2 charting 4th hourly

ON DAY 4 :

Diagnosis : DIABETIC KETOACICOSIS [RESOLVED]

No c/o : fever spikes 

O/E 
Patient is c/c/c 
temperature: afebrile
BP : 110/70 mm Hg
PP : 82 bpm , regular
CVS : S1 , S2 present
RS : BAE present
P/A : soft non tender

1. IVF NS @100ml/ hr
2. Inj. NPH SC/BD, HAI SC/TID
3. Inj.PAN 40mg IV/OD
4.Inj. Zofer 4mg IV/TID
5.Tab.PCM 650 PO/SOS
6.SYP.Cremaffin 15ml PO/SOS
7.SYP. Ambroxol 5ml/PO/SOS
8.Tab. Citrizine 5mg/PO/OD
9.Tab. Pregabalin 75mg/PO/HS
10. BP/PP/RR/SPO2 charting


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