GEN-MED E-log

 Hi, This is Vaishnavi Manga, an eighth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.

I have 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.

A 65yr old with DKA 2° to CAP with AKI

Case:

A 65year old male who is a resident of thurkapallem, shop keeper by occupation came to opd with

Chief complaints: 

Fever since 6days.

Breathlessness since 3days.

History of present illness:

Patient was apparently asymptomatic 10days back then he developed cold and cough with expectoration which is greenish and mucoid, no aggaravating and relieving factors. Now the expectoration has subsided.

No h/o hemoptysis.

Then developed fever 6 days back which is high grade, continuous and not associated with chills and rigor.and took medication from local RMP and got subsided.

Complaints of decreased appetite since 4 days.

Shortness of breath since 3day - grade II now increased to grade - IV since last night.

H/o nausea but no vomitting.

No h/o decreased urine output, pedal edema and loose stools.

No h/o tightness of chest.

DAILY ROUTINE: 

He is a shopkeeper by occupation according to the attender his daily routine is as follows 

6 am: takes a cup of tea with sugar 

6:30 am: he opens his shop

If he takes a breakfast it's b/w 7-7:30 am

9 am: takes a cup of tea with sugar

11 am: bathes and goes to his shop again

12:30 pm: he eats his lunch 

4:30-5:30pm: he again consumes rice

6:00 pm: takes a cup of tea with sugar 

7:30 pm: takes his dinner which consist of rice 

9 pm: he sleeps

PAST HISTORY

N/K/C/O DM, HTN, TB, Epilepsy, CVA, CAD.

Complaints of pain in bilateral knee joints for which he takes NSAIDS when pain increases.

H/o Surgery for right tibial fracture 5 years back

PERSONAL HISTORY

Diet : Vegetarian

Appetite : Normal before 3 days and taking only 2 meals per day and he is denying taking food.

Sleep: adequate

Bowel and bladder : Normal

Addictions : used to smoke 2 packs per day but stopped 5 years back

FAMILY HISTORY

Not significant

GENERAL EXAMINATION

Patient conscious coherent and not co-operative.

Moderately built and nourished.

Pallor present, no icterus, cyanosis, lymphadenopathy, pedal oedema.

VITALS

Pulse : 118bpm

RR :  21 cpm 

BP :  90/60 mm Hg

Temp. :  102°F

SpO2 : 96%

GRBS : high

SYSTEMIC EXAMINATION

CVS : S1, S2 hear, no thrills and murmurs 

Respiratory system: 

On inspection: normal chest shape,position of trachea - central

No scars,sinuses,engorged veins

Abdominothoracic type of respiration

NVBS +

decreased breath sounds in infra axillary and mammary area

Dysnea, wheeze, rales and ronchi - absent

On palpation:- all inspectory findings are confirmed on palpation. 

On percussion:- right              left              

Infraclavicular       resonant            resonant

Mammary          dullnote.            resonant

                                                

Axillary.               resonant                  resonant 

Infraaxillary.       dullnote.                resonant

Suprascapular.       resonant.            resonant

Infrascapular.           dullnote        resonant

Upper, mid, lower.    resonant.      resonant

Interscapular.           resonant.        resonant

On auscultation:- normal vesicular breath sounds heard and decreased breath sounds in right inframammary,infra axillary,infrasacpular areas.

Per Abdomen: scaphoid shaped, soft and diffuse tenderness 

CNS:

Drowsy, arousable

Slurred speech

No neck stiffness

Cranial nerves

Tone: normal in both limbs

Power:4/5 in both limbs

Reflexes:                     Right.                      Left

Biceps.                          ++.                          ++

Triceps.                          ++.                         ++

Supinator.                      +                          +

Knee.                             ++.                          ++

Ankle.                            ++.                           ++

Plantar.                         Flexor.                   Flexor 

Cerebellar Examination: Normal

PROVISIONAL DIAGNOSIS:

Diabetic ketoacidosis secondary to respiratory disease 

Investigations:

Glucose Monitoring Chart:

FINAL DIAGNOSIS:

        

          Diabetic ketoacidosis with community acquired pneumonia with prerenal AKI

TREATMENT 

2/12/2023

1) NBM until further orders

2) IV Fluids NS @ 100ml/hr

3) Inj. PIPTAZ 2.5gm IV/TID

4) Inj. LINEZOLID 600mg IV/BD

5) Tab. AZITHROMYCIN 500mg OD

6) Tab. FLUCONAZOLE 150 mg OD

7) Inj. HOMAN ACTRAPID INSULIN infusion @ 6units/hr

8) Inj. PCM 18g IV/SOS ( if temp. >= 101°F)

9) Inj. LASIX 20mg IV/BD ( if SPB >= 110)

10) IV Fluids - FRUSIDEX @ 50ml/hr

11) Tab. ATORUAS 40mg OD

12) Tab. CLOPITAB - A75/75 OD

13) Inj. PAN 40mg IV/OD

14) GRBS moniter hourly

 

15) Moniter BP, PR, RR, SPO2 Hourly

8:40 PM

1) Stop insulin infusion

2) Inj. HAI 6U in 500ml DNS over 5hrs

3) Inj. KCL 20mEq in 500 NS over 5hrs

Followed by 

4) Inj. KCL 20mEq in 500 NS over 5hrs

5) GRBS moniter hourly

3/12/2023

1) Inj. PIPTAZ 2.25gm IV/TID

2) Inj. LINEZOLID 600mg IV/BD

3) Tab. AZITHROMYCIN 500mg OD

4) Tab. FLUCONAZOLE 150 mg OD

5) Inj. PAN 40mg IV/OD

6) Inj. PCM 1g IV/SOS ( if temp. >= 101°F)

7) Inj. LASIX 20mg IV/BD ( if SPB >= 110)

8) Inj. HOMAN ACTRAPID INSULIN infusion  S/L TID according to GRBS

9) Tab. ATORUAS 40mg OD

10) Tab. CLOPITAB - A75/75 OD

11) GRBS moniter 2 hourly

12) Moniter BP, PR, RR, SPO2  2 Hourly

13) Nebulization with IPRAVENT 8th hourly and BUDECORT 12th hourly

14) Inj. KCL 20mEq in 500 NS over 5hrs

15) Tab. FENOFIBRATE 160mg OD

16) Tab. METOPROLOL 25mg OD

17) IV fluid DNS with 6u HAI + 20mEq KCl at 100ml/hr

4/12/23

1) Calcium gluconate 1 amp iv stat

2) inj 25% dextrose + 10 IU actrapid iv stat