Final assessment-Long case

 February 8th,2022

This is an 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

A 60year old male patient presented to the OPD complaining of loss of consciousness since 4days and one episode of vomiting the next day

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 12 years back.

He then developed diabetes for which he is taking medication since 12years

He used to take a regular dose of insulin IV and Glimepiride to control the sugar levels 

One year back patient had burnt injury due bike silencer for which he did not take proper medication.Later the injury got infected and developed non healing ulcer which finally led to amputation of his three toe fingers 4months back.

After the surgery he stopped taking insulin IV and started taking Glimepiride bd

5Days back he attended a function where he took 90ml of alcohol and also he skipped his medication on that particular day.

On that particular day he fell unconscious due uncontrolled sugar levels and had one episode of vomiting the next morning.Vomiting -food as particles,non-projectile and non-bilious in nature

HISTORY OF PAST ILLNESS 

Known case of DM since 12years

He underwent amputation 4months back

Patient has habit of consuming alcohol since 15years 

Initially he used to consume alcohol daily -180ml

After the surgery he started consuming occasionally 

No history of hypertension,asthma,TB,epilepsy 

PERSONAL HISTORY 

Diet- mixed

Appetite- normal

Sleep- adequate

Bowel and bladder movements- regular

FAMILY HISTORY 

History of diabetes was also found in patients siblings 

GENERAL EXAMINATION:

Patient is conscious,coherent,cooperative and well oriented to time and person

Pallor +

No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Mild dehydration +

Vitals at admission:

Temp.- Afebrile

PR- 91 bpm

RR- 24 cpm

BP- 220/110 mmHg

SpO2- 97% at RA

SYSTEMIC EXAMINATION:

CVS: S1S2 heard, no murmurs

RS: BAE+ NVBS+

P/A: Soft, Non-tender,no palpable masses present

CNS:conscious,speech normal reflexes normal

PROVISIONAL DIAGNOSIS 

Uncontrolled sugar levels associated with DKA

INVESTIGATIONS 

 

 

COMPLETE BLOOD PICTURE

Hb-13.2%

TLC-12500 cells/mm3

Platelet count-3.65 lakhs/mm3

CARDIOVASCULAR EVENT

Albumin +

Sugar +++

Pus 1-2

RBC-nil

LIVER FUNCTION TEST

TB-1.63mg/dl

DB-0.47mg/dl

ALP-158 U/L

TP-7.3g/dl

Albumin-4.3g/dl

RENAL FUNCTION TEST

Creatinine-1.3mg/dl

Urea-34 mg/dl

Sodium-134 mEq/L

Potassium-4.1 mEq/L

Chlorine-96mEq/L

TREATMENT 

1. IVF - NS @ 125 ml/hr continuous IV

2. Inj. HAI 6U IV STAT

3. Inj. Thiamine 2 amp in 100 ml NS IV STAT followed by Inj. Thiamine 1 amp in 100 ml NS IV/OD

4. Inj. Zofer 4 mg IV SOS 

5. Inj. Lorazepam 1 ml in 4 ml NS @ IV STAT

6. Inj. Monocef 1 gm IV BD

7. Foley's catheterisation

8. Tab. Nicardia 10 mg PO STAT

9. Vitals monitoring 4th hourly

10. GRBS monitoring every hour

Glimepiride 

Potassium chloride 

Midazolam

Lorazepam

Vitamin B-12