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.
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.
CASE:
A 57 year old male patient who is a resident of nalgonda and farmer by occupation (lemon field)came to the casualty with altered sensorium since 1 day and Generalised weakness since 1 day.
History of presenting illness:
Patient was apparently asymptomatic 1 year back . In Feb 2022 he started to talk irrelevantly and unable to recognize his family members so they went to a local Rmp who informed the patient attenders that patient is having high sugars and got admitted here to kamineni and diagnosed him with ?DKA. He got few high bp recordings at that time. He also got diagnosed with ckd and having chronic pancreatitis. He had 3 days of hospital stay and and was on HAI (10U(initially 8U)-----X-----12U). Since then he was coming to regular check up every 3 months.
He was alright since then. But the patient thought his sugars were in control so he stopped taking insulin since 2 days ( last dose was Monday morning 8am). Yesterday night on 25-7-2023 he again started to talk irrelevantly (altered sensorium)and Generalised weakness. Low grade fever which got subsided with medication (DOLO 650mg).
Today morning at 11am went to rmp and said to have high sugars and got admitted here in our hospital.
H/o weight loss since 1 year.
H/o headache since 1 day.
No h/o vomitings , abdominal pain, sob, palpitations.
Daily routine:
His occupation is agricultural worker (lemon field)
Before 1 year(before he got diagnosedwith diabetes)-
The patient used to eat rice 3 times a day and goes to work at 9 am and comes back to home at 5 am and watches TV and sleeps at 8 pm after having food.
After he got diagnosed with DM 2 -
He changed his dietary habits. He eats Gatka(made of jonna)(HAI 10U) as breakfast and drinks milk. And goes to work at 9am and at 1pm he has rice for lunch and at 5 pm he gets back from fields and drinks milk and watches TV and has royi at 7pm and takes his night dose of insulin (HAI 12 U)and goes to sleep at 8 pm.
Past history:
IN 2021 He had cough with sputum(muvoid) fir 2 yo 3 days and got tested positive for TB (compliant with 6 months ATT therapy). And gotbtested negative for tb after 6 konths of therapy.
K/c/o diabetes since 1 year on HAI (10U-----X-----12U)
Not a known case of Hypertension, asthma epilepsy, CAD,CVA
Personal history:
Diet-mixed
Appetite-normal
Sleep-adequate
Bowel and bladder movements-regular
Addictions- alcohol intake and toddy deinker since 30 years daily since 1 year occasional drinker . Beedi smoker (10-15/day) and cigarette smoking occassionally stopped smoking since 1 year.
Family history:
Not significant
General examination:
Patient is non coherant,conscious, cooperative
Moderately nourished and moderately built .
No pallor,Icterus, cyanosis, clubbing lymphadenopathy, edema
Vitals:
Temp:99.1F
BP- 120/70 mmhg
PR- 88 bpm
RR-20 cpm
Grbs-650 mg/dl
Systemic examination:
CNS:
Patient is not coherant
Speech -normal.
Cranial nerve examination-normal
Tone-normal.
Power-5/5 in all limbs.
Reflexes: Right left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle + +
Plantar flexor flexor
Cerebellar examination-normal.
CVS-s1,s2 heard and no murmurs.
RS- BAE +, NVBS
P/A- Soft and nontender.
Provisional diagnosis:
Diabetic ketoacidosis secondary to non compliance to insulin.
Investigations:
On 26-07-2023
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