36 YEAR male patient with uncontrolled sugars

 

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.


Chef complaint:

36YR Old male patient came with complaints of Pain in the Left arm and Fore arm 

HISTORY OF PRESENT ILLNESS 


Patient was apparently asymptomatic 15days ago , then he developed pain ,which is insidious in onset ,gradually progressive in nature , dragging type ,continuous , aggravating on moving Left Upperlimb ,No relieving factors 

No H/O fever 

No H/O trauma 

No H/O ulcers ,Depigmentation ,eczema 

K/c/o  DM 4 years is on irregular medication, 

K/c/o pulmonary TB 2 years ago and used ATT for 7 months

N/k/c/o HTN, Asthma, epilepsy, CVA, CAD, thyroid disorder 

Personal History:

Appetite: Normal

Diet:mixed

Bowel and bladder: regular

Habits:alcholic since 17 years

Family History: non significant

General examination 

Patient is Conscious, Coherent , Cooperative

Temp : Afebrile 

BP : 130/70 mmHg 

PR : 86bpm 

RR : 18cpm 

SPO2 : 99% with RA 

GRBS : 168mg/dl @8AM 

I/O : 2500/1400 ml 

CVS : S1 S2 heard ,No murmurs 

RS : BAE + 

CNS : 

Sensory Examination: 

                                               RT LT 

POSTERIOR COLUMN :

Fine touch N decreased over dorsum of foot 

Vibrations                  

Medial Malleolus. 5.57secs ---

Tibial Shaft 15secs 13.5 secs 

Great toe 7.24 secs ---


Proprioception 7/10 8/10 

Rhombergs sign ---- ----


SPINO THALAMIC :

Crude Touch N decreased on dorsum and plantar aspects of foot 

Pain N N 

Temperature N decreased on dorsum of foot 


CORTICAL :

2 Point Discrimination + + 

Tactile Localisation + + 

Graphesthesia decreased over + 

                                      shaft of tibia 

Stereognosis + couldnt elicit 

MOTOR EXAMINATION: NORMAL 

P/A : Soft ,Non Tender

Blood urea

ecg

serum creatinine 

RBS



cbp

usg_Axilla

Cue

HEMOGRAM 

fever chart

2D echo





Diagnosis 

Uncontrolled Sugars -DM 2 since 5yrs ( On irregular medication) , Hyponatremia (Hypo Osmolar ) , Lt Upper limb cellulitis , Renal AKI (Non oliguric ) on Diabetic Nephropathy, with Past History of Rt Pulmonary TB (2 yrs ago ,used ATT for 6 months ) with Anemia under Evaluation (Normocytic ,Normochromic ) 


Treatment :

1/2/23

Inj .HAI s/c accordingly to grbs

Inj. NPH s/c acc to grbs

Inj. Monocef 1g /iv/BD

Inj. Metrogyl 500 mg/ iv/TID

Regular dressing

Limb elevation left UL

2/2/23

IV fluids NS @ 100ml/hr 

Inj . HAI S/C according to GRBS 

Inj. NPH S/C according to GRBS 

Inj. Monocef 1gm IV /BD 

Inj .Metrogyl 100ml /IV /TID 

Inj .Thiamine 200mg in 100ml NS IV /OD 

Inj. Optineuron 1 amp in 100ml NS IV /OD 

Inj .Pan 40mg IV/OD /BBF 

Inj. PCM 1gm IV/SOS (if Temp > 101F ) 

Tab .Dolo 650mg PO/TID 

Tab . Chymoral Forte PO/TID 

Left Upper Limb Elevation 

4-5 egg whites /day 

Strict Diabetic Diet 

Regular Dressings 

GRBS 7 Point Profile 

Monitor Vitals 4th Hrly

3/2/23

IV fluids NS @ 100ml/hr 

Inj . HAI S/C according to GRBS 

Inj. NPH S/C according to GRBS 

Inj. Monocef 1gm IV /BD 

Inj .Metrogyl 100ml /IV /TID 

Inj .Thiamine 200mg in 100ml NS IV /OD 

Inj. Optineuron 1 amp in 100ml NS IV /OD 

Inj .Pan 40mg IV/OD /BBF 

Inj. PCM 1gm IV/SOS (if Temp > 101F ) 

Tab .Dolo 650mg PO/TID 

Tab . Chymoral Forte PO/TID 

Syp .Potklor 10ml PO/BD 

Left Upper Limb Elevation 

4-5 egg whites /day 

Strict Diabetic Diet 

Regular Dressings 

GRBS 7 Point Profile 

Monitor Vitals 4th Hrly 

4/2/23

IV fluids NS @ 100ml/hr 

Inj . HAI S/C according to GRBS 

Inj. NPH S/C according to GRBS 

Inj. Monocef 1gm IV /BD 

Inj .Metrogyl 100ml /IV /TID 

Inj .Thiamine 200mg in 100ml NS IV /OD 

Inj. PCM 1gm IV/SOS (if Temp > 101F ) 

Tab .Dolo 650mg PO/TID 

Tab . Chymoral Forte PO/TID 

Syp .Potklor 10ml PO/BD 

Left Upper Limb Elevation 

4-5 egg whites /day 

Strict Diabetic Diet 

Regular Dressings 

GRBS 7 Point Profile 

Monitor Vitals 4th Hrly








Comments

Post a Comment

Popular posts from this blog

56 YEAR OLD MALE WITH ACUTE EXCERABATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Image
 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 PRESENTATION  CHIEF COMPLAINTS:   . DIFFICULTY IN BREATHING SINCE 15 DAYS  .COUGH SINCE  15 DAYS  HISTORY OF PRESENT ILLNESS :  PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS BACK THEN HE DEVELOPED SOB OF
Read more

46 Y old male patient with B/L swelling of lower limbs since 1 month

Image
 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. Cheif complaints: B/L swelling of lower limbs since 1 month Shortness of breath since 1 month Abdominal Distension since 1 month Cough since 3 days  History of present illness: Patient was apparently asympto
Read more

DENGUE FEVER WITH THROMBOCYTOPENIA

Image
 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 PRESENTATION  CHIEF COMPLAINTS:   COMPLAINTS OF FEVER SINCE 3 DAYS   VOMITING SINCE 3 DAYS  HISTORY OF PRESENT ILLNESS : PATIENT WAS  APPARENTLY ASYMPTOMATIC 3 DAYS AGO THEN HE DEVELOPED FEVER WHICH IS
Read more