A 38 year man with shortness of breath

-
This is an online E - log book to discuss our patients 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 portfolio and your valuable inputs on the comment box

7/9

A 38 year male presented to OPD with cheif complaints of shortness of breath and vomitings

Cheif complaints:

Shortness of breath grade 4 since yesterday night
Vomitings - 4 to 5 episodes per day since yesterday morning

History of presenting illness:

Patient was apparently alright till 2 days ago then he had his last binge of alcohol during evening at about 6 pm. He didn't had any meal on that day and didn't took his medications for his diabetes.

Next day morning(yesterday) at about 8 am he was having vomitings which are non bilious, clear(no colour), watery, projectile vomitings without any food particles 4 to 5 times associated with abdominal and chest pain - diffuse and dull type.

On that day(yesterday), he developed generalised weakness so he consulted to a local RMP at about 8:30pm evening. He was administered with 2 bottles of saline and then his blood sugar level was more than 600mg/dl (as per his wife).

Then later at night at about 9 pm he came back to home and he started developing shortness of breath grade 4. He didn't had any meal and didn't took his medications for his diabetes.

Next day(today) he was admitted to our hospital, morning at 7:15 am

History of past illness:

He is known case of diabetes since 1.5 years which he was diagnosed when he had complaints of polyuria for a week

K/c/o diabetes - 1.5 years on insulin and metformin 500 mg/ BD

N/k/c/o HTN, Thyroid disorders, CAD, Epilepsy, Asthma, TB

Medication history:

He doesn't take tablets on the day when he consumes alcohol

Insulin and metformin 500 mg/ BD since 1.5 years

Daily routine:

He wakes up at about 8 am
He does his breakfast at about 8:30 am which is usually rice with curry
He goes to work by 9 am with his wife
He has lunch with his wife at about 1 pm which is usually rice with curry (again)
At about 6 pm he and his wife returns to their home
They usually have dinner at about 9 pm which is usually rice with curry(again)
They sleep by 10 pm

Personal history:

He is married - 15 years
Mason by occupation
Appetite - normal
Non vegetarian
Regular bladder and bowel movements
No allergies
Addictions/habits:
1. Alcoholic since 10 years
Frequency - once in about 10 days
Volume of consumption is about 180 ml(quarter)
2. Smoking since 10 years
Frequency - about 3 per day


Family history:

His father is diabetic since 4 years
His grand father was also a diabetic (expired)

General examination:

Temperature : 93.7 F
BP : 90/60 mm Hg
PR : 100 bpm
RR : 28 cpm
SpO2 : 96%
GRBS : > 500 mg/dl

No pallor / icterus / cyanosis / clubbing / lymphadenopathy / Oedema


Abdominal inspection:


Systemic examination:

A. Cardiovascular system :

• S1, S2 are heard
• No thrills and no cardiac murmurs

B. Respiratory system:

•  dyspnoea present
    no wheezing
• Position of trachea - central
• Breath sounds - Vesicular

C. Per Abdominal Examination:

Shape of abdomen - scaphoid
• No Tenderness 
• No palpable mass / free fluids / bruits
• Liver / spleen not palpable

D. Central Nervous :

No signs of meningeal irritation


Investigations: 

ECG

Temp/BP/PR/RR/SpO2/GRBS monitoring:

Provisional diagnosis:

Diabetic ketoacidosis

Treatment:

Day 1

IV fluids NS continuous @ 125 ml /hr
Inj HAI 6U/IV/Stat
Inj HAI 1ml in 39 ml NS @ 6 ml /hr
Inj PAN 40mg/IV/OD/BBF
Inj Zofer 4mg/IV/BD
Hourly GRBS monitoring
Monitor vitals and inform SOS

Day 2

IV fluids NS,RL,5% dextrose @100ml/hr
Inj HAI 1ml in 39 ml NS infusion @ 6ml/hr
Inj PAN 40mg/IV/OD/BBF
Inj Zofer 4mg/IV/BD
Hourly GRBS monitoring
Monitor vitals and inform SOS

Day 3

IV fluids NS,RL @100ml/hr
1 Amp Optineuron
Inj NPH SC/BD/premeal
140------x------120
Inj HAI SC/TID/premeal
90------90------90
Inj PAN 40mg/IV/OD/BBF
Inj Zofer 4mg/IV/BD
GRBS profile monitoring
Monitor vitals and inform SOS

Comments

Post a Comment

Popular posts from this blog

90 Mutyapu Raghavendra

-
Medicine Department Bimonthly Blended Assessment - June 2021 This is the link to assignment/question paper :- https://medicinedepartment.blogspot.com/2021/06/medicine-department-paper-for-june-2021.html?m=1 I have been given the following assessment in the theme of “scholarship of integration in medical education and research” which is a tool to facilitate connections between different systems or disciplines of “knowledge” or learning in healthcare. Question 1 :- 1. Pulmonology:- Review of :- https://caseopinionsbyrollno05.blogspot.com/2021/05/medicine-blended-assignment-may-2021.htm This is a case of acute exacerbation of COPD associated with right heart failure and bronchiectasis. The evolution of the symptomatology in this patient in terms of an event timeline is depicted well in a picture which is very easy to comprehend. I personally believe that a picture can depict more than a thousand words. The localisation of the problem along with its aetiology is addressed. Various mechanis
Read more

A 29 year male with chronic kidney disease secondary to NSAID abuse

-
Image
This is 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 patients 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 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 diagnosis and treatment plan A 29 year male agricultural coordinator by occupation came to opd with chief complaints of  Bilateral pain in lower limbs upto knee since 20 days HOPI Patient was apparently asymptomatic 3 years ago then developed sev
Read more

A 20 year female with pedal edema and decrease bowel & bladder movements

-
Image
This is an online E - log book to discuss our patients 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 portfolio and your valuable inputs on the comment box. 28/9/2022 A 20 year female came with chief complaints of : B/L pedal edema extending till the knees since 20 days Abdominal distension since 8 days Decreased bowel and bladder movements, decreased appetite, decreased width of opening mouth & intensity of sound, throat pain since 3 days History of presenting illness: Patient was apparently asymptomatic 1 month back 1 month ago she developed pedal edema grade 3 (upto knees) and burning pain on sole B/L She went to local RMP for which she got treated and
Read more