GENERAL MEDICINE ELOG-03 AUGUST-30,2021

DIVYA POLAGONI

ROLL NO:01

OLD BATCH

3rd Semester

Under the guidance of Dr. Manasa (intern) 

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.

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 a diagnosis and treatment plan. 

CASE SCENARIO 

*A 55 yr old male came to casuality with cheif complaints of fever since 6 days and unable to walk since 4 days.

HISTORY OF PRESENTING ILLNESS

*2 days back he was taken to a local hospital.When his GRBS was around 300 and ketone bodies found in urine.

*Low grade intermittent fever since 5-6 days

*Generalized weakness and unable to do his daily routine since 4 days

*Got tested there and brought to our hospital for further treatment.

*No other complaints 

HISTORY OF PAST ILLNESS 

-Type 2 DM 

-Taking OHA since 7yrs

-Not a k/c/o Asthma/Epilepsy/TB/HTN

TREATMENT HISTORY 

*No h/0 Hypertension,CAD, Tuberculosis, Asthma, Antibiotics, Hormones, surgeries, Blood transfusion.

PERSONAL HISTORY 

*Married

*Occupation - farmer  

* Non vegetarian

* Lost appetite

*Bowels-Irregular

*Micturition- normal

*No known allergies

Addictions

*Occasionally consumes alcohol and smokes tobacco since 20 years.

FAMILY HISTORY

*Diabetes - No

*Asthma - No

*Hypertension - No

*Heart disease - No

*Stroke - No

*Cancers - No

*Tuberculosis - No










GENERAL EXAMINATIONS 

*No-Icterus/Cyanosis/Lymphadenopathy/Malnutrition 

*Temperature -100F

*Pulse rate - 130beats /min

*Bp - 80/50 mm/hg

*SpO2 - 96%

*GRBS - 425 mg%

SYSTEMIC EXAMINATION

CVS:  

-No Thrills

-Cardiac Sounds - S1, S2 +

-No cardiac murmurs

RESPIRATORY SYSTEM: 

-Dyspnoea - No

-No Wheezing

-Position of Trachea - central

-Vesicular sounds 

ABDOMEN:

-Shape - Scaphoid

-No palpable mass

-Bowel sounds- present

CNS:

-Level of consciousness - conscious

-Glassgow scale -E4 V5 M6

GAIT, MUSCULO SKELETAL SYSTEM, SKIN, EXAMINATION OF ENT, HEAD AND NECK - NORMAL 

PUSTULAR LESIONS SEEN IN ORAL CAVITY

PRESENT ON HARD PALATE AND OROPHARYNX

INVESTIGATIONS:-


 
ULTRASOUND

*Investigation reports on 27/8

-Serum creatinine - 1.5mg/dl

-SGPT -40 IU/L

-SGOT  - 24 IU/L

-ESR - 100 mm/first hr

-ALKALINE PHOSPHATASE - 279 IU/L

-BLOOD UREA - 158 mg/dl

-SERUM PROTEIN - 6.2g/dl

-RBS - 424mg/dl



*Investigation reports on 29/8

-HB1Ac - 7.4%

-SERUM CREATININE -2 mg/dl

-BLOOD UREA - 180 mg/dl

*PROVISIONAL DIAGNOSIS

?community acquired pneumonia 

Type-2 DM with uncontrolled sugars

TREATMENT:-

-IV fluids 20 NS IV/Bolus

-IVF 0.9% NS 100ml/hr

-INJ PAN 40mg  IV/OD

-INJ ZOFER 4 mg IV/sos

-INJ HAI for every 6hrs

- INJ NPH for every 12hrs 

-INJ OPTINEURON 1amp in 100ml NS IV/OD

-TAB Dolo 650mg  TID






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