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Here we discuss individual patient's problem through series of inputs from patient's attendees and investigations done, with an aim to solve those patients problems with collective current evidence based inputs.
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G.NEHAREDDY,
Roll.no. 31
CASE DISCUSSION
I have been given this case to solve in an order to attempt to understand the topic of patient clinical data including History,clinical findings, investigations and come up with a diagnosis and treatment plan
A 55year year old male , On 25/8/21 has come to hospital with
Cheif complaints :
• seizures an hour ago ( uncoincious)
History of present illness :
patient was apparently asymptomatic 3 years back then he developed shortness of breath (SOB)which made him to stop smoking, SOB was insidious in onset ,gradually progressive where he had taken tablets for 2 months then he felt relieved and stoped the medication. later he had sob once in a while then he experienced increased sob (grade 4) 4days ago where he can't go out ofthe house but can do his daily routine .aggravated on walking and releived on taking rest/laying down.
Due to increase in sob he went to an local hospital, then he had an episode of seizures i.e, developed stiffness in both upper and lower limbs with repititive blinking of eyes for 2minutes followed by involuntary micturation. No history of uprolling of eye balls,tongue bite nor frothing of mouth.
The patient didn't regain consciousness thereafter.Similar episode occured in hospital,which lasted for 2 minutes and Another episode occurred after 15min followed the 2nd episode again lasting for 2min. The patient didn't regain consciousness in between the episodes
after 1hr the patient became irritable.
No History suggestive of orthopnoea , paroxysml nocturnal dyspnoea.
cough is insidious in onset occurs once in a while along with sob, aggravated on walking and relieved on taking medications, not associated with sputum.
History of past illness
patient is a chronic alcoholic who consumes 180mlwiskey/day and
he is also a chronic smoker who had been smoking about 40 bedies /day for the past 30yrs.
he quit smoking 3yrs ago due to sob as suggested by the doctor who aslo asked to quit alcohol but he didn't
he stoped consuming alcohol since 10 days due to increase sob.
he is not a know case of hypertension, diabetes, asthma ,epilepsy ,tuberculosis.
Personal history
diet-mixed
appetite - normal
sleep -adequate
bowel and bladder moment -regular
addictions - smoking bedies & consumes alcohol
Family History
not significant
General Examination
patient was unconsious when brought to the hospital for about an hour.
on 26th
later patient was consious ,coherent but not cooperative and not oriented to time place and person.
on 27th
he is conscious coherent and cooperative and well oriented to place and person
pallor,icterous,cyanosis,clubbing,lymphadenopathy,edema are absent
VITALS
Temperature - afebrile
respiratory rate - 23cpm
pulse rate- 143bpm
blood pressure - 100/80mm Hg
Systemic examination
cvs :
s1 s2 heard
no murmurs
Respiratory system :
no wheeze
trachea position is central
bilateral air entry present
Abdomen :
shape- scaphoid
no tenderness,palpable mass
liver and spleen not palpable
normal bowel sounds
Investigations
Hemogram
hemoglobin :14.6gm/dl
total count: 15,600 cells/cumm( increased)
neutrophils:85
lymphocytes : 13
monocytes :01
basophils :00
Random blood sugar -731mg/dl
Serum osmolality - 313m osm/ kg ( increased)
Serum creatinine - 1.4 mg/dl
Blood urea - 83mg/dl
Serum electrolytes
on25th on26th
Na - 130mEq/l 137mEq/l
k - 4.2mEq/l 3.8mEq/l
Cl - 95 mEq/l 102mEq/l
URINE Ex.
urine ketone bodies - Negative
albumin +
sugar ++++
Liver Function Test
direct bilirubin- 0.30mg/dl ( N-- 0.0-0.2 )
alkaline phosphate - 223 IU/L(N=53-128)
CHEST X-RAY
2D Echo Report screening
Diastolic dysfunction present
inferior vena cava size (1.19cms) i.e, IVCdilated
dilated right atrium/right ventricle/IVC
Diagnosis
Diabetic ketoacidosis , hyperglycemic seizures with Right heart failure
celulitis in the upper limb.
Treatment
on 25th
inj. actrapid insulin 6U IV stat
HAI infusion at 6ml/hr ( 40IU=1ml HAI+ 39mlNs)
IVF - Ns at 100ml/hr
inj.lorazepam 2cc IV
T/o charting
monitor bp,pR,RR,SPO2
inj. Thiamine 1amp 1N 100ml Ns IV BD
on 26th
inj. lorazepam iv
inj.levipil 500mg iv bd
inj. HAI 3 units iv stat
inj. metrogyl 1gm iv
inj lasix iv
on 27th
inj.monocef 1gm iv bd
inj. metrogyl 100 ml iv Tid
inj. actrapid stat
inm. lasix 40mg bd
inj 5% dextrose 50ml
ivf. Ns 100m, Tid
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