This is an a 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.
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 diagnosis and treatment plan
PATIENT WAS BROUGHT TO CASUALITY IN UNRESPONSIVE STATE.
PATIEN WAS APPARENTLY ASYMPTOMATIC 3 YEARS BACK THEN SHE DEVELOPED GENERALISED WEAKNESS FOR WHICH SHE VISITED LOCAL HOSPITAL AND WAS DIAGNOSED WITH TYPE 2 DM. SINCE THEN PATIENT WAS ON IRREGULAR MEDICATION. TODAY MORNING PATIENT ATTENDERS NOTICED THAT PATIENT WAS IN UNRESPONSIVE STATE AND WAS UNABLE TO WAKEUP FROM SLEEP AND WAS TAKEN TO LOCAL RMP (HIGH SUGARS 600 MG/DL WAS OBSERVED) AND WAS REFERRED TO OUR HOSPITAL IN UNRESPONSIVE STATE, HER GCS - E1V1M6.
NO H/O ABNORMAL MOVEMENTS, HEADACHE,VOMITING. K/C/O DM2 SINCE 3 YRS AND ON IRREGULAR MEDICATION.
NOT K/C/O HTN,ASTHMA, CAD, EPILEPSY. PERSONAL HISTORY :
APPETITE - NORMAL
DIET - MIXED
BOWEL AND BLADDER - REGULAR
SLEEP - ADEQUATE
ADDICTIONS : OCCASIONAL TODDY-ONCE A WEEK
TOBACCO(BEEDI) FROM 20 YEARS, STOPPED 3 YEARS AGO
GENERAL EXAMINATION :
NO PALLOR, ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY,PEDAL EDEMA
VITALS ON ADMISSION:
TEMP- 101 F
PR-90 BPM
BP- 100/70MM HG
RR- 20 CPM
SPO2- 97% AT RA
GRBS - 226 MG/DL
SYSTEMIC EXAMINATION:
1) PER ABDOMEN:
INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.
PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.
ASCULTATION: BOWEL SOUNDS - HEARD
2)RESPIRATORY SYSTEM:
INSPECTION:SHAPE OF THE CHEST IS ELLIPTICAL,B/L SYMMETRICAL.BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.
PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL .VOCAL FREMITUS IS NORMAL
PERCUSSION: RESONANT B/L
ASCULTATION: BAE + , NVBS HEARD
3) CVS:
INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.
PALPATION: APEX BEAT FELT IN LEFT 5TH ICS.NO THRILLS AND PARASTERNAL HEAVES.
ASCULTATION: S1S2 +,NO MURMURS
4) CNS:
GCS - E1V1M6
B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT
NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEM- NORMAL,
MOTOR SYSTEM: TONE- NORMAL, POWER- 0/5 IN RIGHT UL AND LL , 2/5 IN LEFT UL AND LL REFLEXES : BICEPS - 1+ , TRICEPS-1+ , SUPINATOR - 1+ ,KNEE - 1+ , ANKLE - 1+
Investigations:
1)HEMOGRAM:
29/01/23
HB : 13.0 mg/dl
PCV : 24.8%
TLC : 13500 CELLS/CUMM PLAT: 1.8 LAKH/CUMM 30/01/23
HB : 11.1 mg/dl
PCV : 34.5%
TLC : 13400 CELLS/CUMM PLT : 1.7 LAKH/CUMM 31/01/23
HB : 10.6 mg/dl
PCV: 33.1 %
TLC : 6900 CELLS/CUMM PLT : 1.7 LAKH/CUMM
01/012/23
HB : 10.8 mg/dl
PCV : 33.3%
TLC : 6700 CELLS/CUMM
PLT : 2.1 LAKH/CUMM
ABG ON 28-01-2023 (04:15:PM)
PH 4.50
PCO2 30.4
PO2 76.6
HCO3 24.0
St.HCO3 : 26.3
BEB : 2.2
BEecf : 1.2
TCO2 : 46.0
O2 Sat : 95.7
O2 Count : 19.5
Serum creatinine :1.2mg/dl
PHOSPHOROUS 28-01-2023:-2.0 mg/dl
HBsAg-RAPID: Negative
HIV : Negative
ANTI HCV : Negative
BLOOD UREA : 28- 56 mg/dl
2)USG ABDOMEN: NO SONOLOGICAL ABNORMALITY DETECTED 3)USG NECK: TRIRADS 3 LESION IN RIGHT LOBE OF THYROID
TRIRADS 2 LESION IN LEFT LOBE OF THYROID 4)BLOOD C/S : NO GROWTH SEEN
5)URINE C/S : E.COLI ISOLATED.
6)2D ECHO : NO RWMA , CONCENTRIC LVH+
TRIVIAL TR+/MR+/AR+
NO AS, MS
EF=62%
GOOD LV SYSTOLIC FUNCTION, DIASTOLIC DYSFUNCTION +, NO PE,PAH.
Diagnosis:
? SEPTIC ENCEPHALOPATHY (SECONDARY TO UROSEPSIS) WITH HYPERGLYCEMIA (RESOLVED) WITH TYPE 2 DM
Treatment :
1.IVF - NS@ 75ML/HR
2.INJ.PIPTAZ 4.5 GM IV/TID
3.T NITROFURONTOIN 100 MG PO/BD
4.INJ PAN 40 MG IV OD
5.INJ KCL 20 MEQ IN 100 ML NS
6.INJ MAGNESIUM 1 AMP IN 100 ML NS
7.T DOLO 650 MG PO/TID
8.SYP POTCHLOR 10 ML PO/TID
9.INJ HAI S/C ACCORDING TO GRBS
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