35 yr male with uncontrolled sugars
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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.
A 35 years old male farmer by occupation presented with
Chief complaints:
Burning micturition since 1 year
Fever since 1 week
vomitings 5 days ago.
HOPI:
Patient was apparently asymptomatic 1 week ago.Then he developed high grade fever which was insidious in onset, gradually progressive in nature, on and off fever , associated with sweats chills and rigors.Temperature raised during afternoon persisted till midnight and decrease after. No aggravating factors and relieved on medication .
He also has a history of 4 -5 episodes of vomiting on each day(2 days) 5 days before admission to hospital . Vomitings had contents as food,non projectile,non blood stained ,non foul smelling and they are after intake of meal.
H/o burning micturition since 1 year associated with white colour urine since 3 days.
H/o generalised weakness since December 2022 but it became severe 1 week ago where patient was unable to move.
H/o constipation since 1 week ( last stool passed on 13/4/2023) .
H/o Anorexia since 5 days .
No H/o fever rash,joint pain ,myalgia,dyspnea, palpitations, diarrhoea,blood in stools, pharyngitis.
No H/o decreased urine output ,increased frequency,increased urgency, hematuria.
No h/o fatigue, nausea, Anorexia, pruritus,altered sensorium ,hiccoughs.
Past history:
K/c/o Diabetes mellitus since 4 months .
K/c/o Anemia since 4 months .
H/o urinary tract infection (December 2022)
Not a known case of Hypertension, Asthma, thyroid disorders,TB, Epilepsy.
Personal history:
Diet mixed
Appetite reduced
Disturbed sleep
Bladder - Burning micturition associated with white color urine
Bowel movements - irregular
Constipation from 9-4-2023 to 13-04-2023) had less than 2 episodes of stools in week.
Family history:
His father is one-sided paralysed.
Treatment history:
Patient was on insulin (inj ) for several months but shifted to oral hypoglycemic agents before 1 month of admission at our hospital.
General examination:
Patient is conscious, coherent and co -operative ,lean
Pallor - present
Icterus- absent
Clubbing - absent
Cyanosis - absent
lymphadenopathy - absent
Edema - absent
Vitals:
Temperature - 100.4 ° F
BP- 120/80 mm hg
PR - 73bpm
RR - 15cpm
GRBS - 363 mg/dl.
Systemic examination:
CNS:
Higher mental functions- intact
Motor system -
Right. Left
Bulk: Normal Normal
Tone:
Upper Limb. Normal. Normal
Lower Limb. Normal Normal
Reflexes: biceps. +. +
Triceps. +. +
Supinator. +. +
Knee. +. +
Ankle. + +
Plantar mute Mute
Sensory examination -
Spinothalamic tract
Crude touch Right Left
Upper limb Normal Normal
Lower limb Normal. Normal
Pain
Upper limb Normal Normal
Lower limb Normal. Normal
Temperature
Upper limb Normal Normal
Lower limb Normal. Normal
Posterior column tract
Fine touch
Upper limb Normal Normal
Lower limb Normal. Normal
Vibrations Normal in upper and lower limbs
Cortical Tract
Tactile localisation
Upper limb Normal Normal
Lower limb Normal. Normal
Stereognosis - Normal
meningeal signs absent
Per abdomen:
Inspection:
Shape of abdomen : flat
Umbilicus : inverted
Movements of abdomen wall with respiration
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
Palpation:
No local rise of temperature
Inspectors findings are confirmed
No tenderness
No palpable mass
Liver and spleen not palpable
Percussion:
B/L resonance heard
Auscultation:
Bowel sounds heard
Respiratory system:
Inspection:
Trachea appears to be normal - Central
shape of chest - elliptical
Movements of chest appear to be bilaterally equal
No scars , sinuses present.
No drooping of shoulder
No engorged veins , swellings seen
No hallowing seen
No crowding of ribs
Palpation:
All inspectory findings are confirmed
No rise of temperature
No tenderness
Trachea is central.
B/L chest movements are equal
No swelling and palpable masses are felt
B/l vocal fremitus are normal
Percussion:
B/L Resonant note heard in all regions.
Auscultation :
Normal vesicular breath sounds heard.
CVS examination :
Inspection:
No raised JVP
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse not seen
Palpation:
Apex beat is felt in the fifth intercostal space, 1 cm medial to the midclavicular line
Auscultation:
S1 and S2 heard, no murmurs are heard
Provisional diagnosis:
Uncontrolled sugars due to non compliance to medication.
with Anemia
Investigations:
Hemogram:-
Hb:- 7.2-6.2-6.8
Pcv:- 22.5-20.4-22.5
TLC:- 22,800-14,480-9,500
RBC:- 3.3-2.89-3.16
Platelets:-4.2-3.47-4.0
RETICULOCYTE COUNT :- 0.5
RFT :-
Blood urea:- 206-147-77
Sr creatinine:- 4.0-3.4-2.3
S.Na:- 131-139-137
S.K:- 4.7-4.0-3.8
S.Cl:- 95-104-106
Ionized Ca:- 1.04-1.08
LFT:-
Total bilirubin:- 1.04
Direct bilirubin:- 0.23
SGPT:- 14
SGOT:-11
ALP:- 284
TOTAL PROTEIN:- 8.0
Albumin :- 2.5
A/G ration:- 0.45
24 hour URINARY ELECTROLYTES:-
Na:- 176
Ca :- 297
Phosphorous:-0.87
Xray
ECG
GRBS on 14 /4/2023.
8 am 170 mg/dl
10 am 140mg/dl
12 pm 102mg/dl
6pm 160 mg/dl
9pm 260mg/dl
Follow up:
16/4/23
2am-98
8am -140-
10am -257
12pm-288
4pm-303
8pm-237
10pm-295
17/4/23
12am-275
2am-210
4am-145
8am-119
10am-199
2pm-187
4pm-157
8pm-121
10pm -188
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