54Y/M with vomitings fever and sob

THIS IS AN 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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 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 

November 26 

Chief complaints : 

C/o fever since 5 days 

C/o sob since 5 days 

C/o vomiting since 3 days 

History of presenting illness : 

Patient was apparently asymtomatic 5 days then had fever since 5 days which is of high grade , associated with chills and not relieved on taking medication 

He complaints of shortness of breath since 5 which is grade 2 ( MMRC) 

No orthopnea and paroxysmal nocturnal dysnea is present 

He also complaints of vomiting since 3 days , 2-3 episodes per day which is non bilious non projectile and watery content 

There was an ulcer over left foot since 1 month which is associated with edema of foot and there is sudden onset of bleb since yesterday 

HISTORY OF PAST ILLNESS

K/C/O DM type 2 since 14 years and is on medication 

Metformin 500 mg and Glimepiride 1 mg 

K/C/O Hypertension since 10 years and is on medication Amlodipine 5 mg 

PERSONAL HISTORY : 

Pt is vegetarian since childhood 

Appetite - decreased 

Sleep - adequate 

Bowel and bladder  movements - regular 

No known allergies 

No addictions

FAMILY HISTORY 

Both of his parents had diabetes 

Father is on medication 

GENERAL EXAMINATION 

Patient was conscious coherent and cooperative 

No pallor icterus clubbing cyanosis generalized lymadenopathy 

Edema is present in left foot upto the ankle 

VITALS 

BP  - 80/60mmhg 

PR - 104bpm

RR - 18 cpm 

Systemic examination 

CVS - S1s2 heard no murmurs 

RR - normal vesicular breath sounds 

PA - soft and non tender and no organomegaly 

CNS - no focal neurological deficit 

INVESTIGATION 

RBS - 311mg/dl 

    

     

 

   

   

      

   PROVISIONAL DIAGNOSIS 

    TYPE 2 Diabetes mellitus 

    Left diabetic foot and HYPERTENSION 

   TREATMENT 

  1) IV fluids NS 100ml/hr 

   2) INJ H. ACTRAPID Sc / TID ( acc to GRBS info ) 

   3) GRBS monitoring 

   4 ) BP monitoring hourly 

   28/11/2023 

O/E 

    PR 92bpm

    BP  140/90

     RR 26cpm 

    GRBS  157mg/dl 

    CVS - s1s2 heard no murmurs 

    PA - soft non tender 

   RR - nvbs 

  CNS - no focal neurological deficit 

  FBS 

  PLBS - 178 mg/dl 

  Rx : 

   1) iv fluids 75ml / hr 

    2) inj AUGUMENTIN 1.2g IV/BD ( 9am ; 8 pm ) 

   3 ) inj PIPTAZ 4.5g TID (8am , 1pm ,8pm ) 

   4 )T linezolid 600mg BD 

   5) inj H ACTRAPID SC TID ( 6u;6u;6u ) 

   6 ) inj NPh sc bd ( 4u ;4u ) 

  7) T LASIX 40 mg bd 

   8) T ecospirin 75 mg OD 

   9) GRBs 

   10 ) temp monitoring 4 hrly 

  11) T AMLODIPINE 5mg OD 

  12 ) T CHYMORAL FORTE bd 

  13) T CILASTOL 100 mg BD 

  14) T ATORVASTATIN 40 mg OD