35 yr old male with SOB and generalized weakness
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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
M.Abhignya
Roll.No. 83
CASE HISTORY:
A 35 YR OLD MALE WHO WAS A TRUCK DRIVER BY OCCUPATION PRESENTED TO CASUALITY WITH C/O SHORTNESS OF BREATH SINCE TODAY MORNING.
INCREASED SLEEPINESS DURING DAY TIME,ALTERED SLEEP CYCLE SINCE 1WEEK.GENERALISED WEAKNESS SINCE 1WEEK
HOPI-
35 year old male who is a tractor driver by occupation, was apparently normal 10 years back, then patient developed fever associated generalized weakness and found to be diabetic and started on OHAs ..Due to uncontrolled sugars patient was started on Insulin after 3 years ( 7 years back).
2 years back, patient started developing Generalised edema along with weakness and decreased urine output,where he had deranged renal Parameters.he stopped going to work and stayed back at home only.He used to take his wife to the field and bring her back to the home.
3 months back, patient developed fever with ulcer over the Right big toe and lower limb , facial puffiness aggravated, brought to our hospital and was admitted and discharged.
Since 7 days onwards , patient had Generalized weakness, and insulin was not given day before yesterday night ,and yesterday morning and patient had sudden onset shortness of breath, associated with altered behaviour and was brought to our hospital.
PAST HISTORY-
K/C/O DM SINCE 10YRS AND ON INSULIN
K/C/O HTN SINCE 2YRS AND ON REGULAR MEDICATIONS
NOT A K/C/O TB/CAD/EPILEPSY/ASTHMA
PERSONAL HISTORY-
MIXED DIET
NORMAL APPETITE
BOWEL AND BLADDER HABITS -REGULAR
ADDICTIONS-CHRONIC ALCOHOLIC AND TAKES DAILY 90-180ML FOR ABOUT 10YRS AND STOPPED 2 YRS BACK
NO ALLERGIES
GENERAL EXAMINATION:
Pallor present
B/l pedal edema present
NO ICTERUS, CYNOSIS, CLUBBING, LYMPHEDENOPATHY,
TEMP- 98F
PR-98BPM
BP-150/100MMHG
SPO2-98% @ RA
GRBS-600 MG/DL(on Admission)
CVS- S1S2+,NO MURMURS
RS- BAE+,NVBS HEARD
P/A- SOFT,NON TENDER,BOWEL SOUNDS+
CNS- ORIENTED TO TIME,PLACE AND PERSON
LEVEL OF CONSCIOUSNESS- DROWSY/AROUSABLE
SPEECH-SLURRED
NO SIGNS OF MENINGEAL IRRITATION
CRANIAL NERVES INTACT
NO SENSORY ABNORMALITY DETECTED
GCS 15/15
B/L PUPILS NORMAL IN SIZE AND REACTIVE TO LIGHT
Investigations:
On 17.02.23.....on19/2/23. ....20/2/23...21/02.....22/02
HB....6.0gm/DC ....5.8 Gm/dl...6.5gm/dl.....6.3gm/dl....8.2gm/dl
Tlc-..21,680.........15,400.....12,000...11,000gm/dl....14,000
Plc-..95,000.…......42,000.....46,000...33,000gm/dl...96,000
Sr.Urea ...99mg/dl..98.........116............108
sr.creat...3.4.......3.4..........
ECG-NORMAL SINUS PATTERN
2D ECHO-
MILD TO MODERATE TR+ WITH PAH, MILD MR+,TRIVIAL AR+
NO RWMA,NO AS/MS,CONCENTRIC LVH+
GOOD LV SYSTOLIC FUNCTION
NO DIASTOLIC DISFUNCTION
BGT-A POSITIVE
Urine for ketone bodies.. Negative
CXR PA view:
17/02/23
ECG :
17/02/23
Diagnosis:
ALTERED SECONDARY TO SEPTIC ENCEPHALOPATHY
HYPEROSMOLAR HYPERGLYCEMIC STATE
K/C/O DIABETIC NEPHROPATHY WITH AKI ON CKD WITH RIGHT DIABETIC FOOT
WITH THROMBOCYTOPENIA SECONDARY TO SEPSIS
Treatment:
NBM TILL FURTHER ORDERS
IVF -NS@ 50ML /HR
INJ. HAI 6U IV STAT F/B 6U /HR
INJ.PIPTAZ 4.5G IV STAT F/B 2.25GIV TID
INJ.CLINDAMYCIN 600MG IV / TID
STRICT I/O CHARTING
GRBS MONITORING HOURlY
ABG AND SR.ELECTROLYTES 6TH HOURLY
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