General medicine prefinals exam case
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Date of admission: 20/12/2021
A 35 year old male patient presented to the hospital with chief complaints of fever associated with chills since 4 days and shortness of breath since 1 day.
History of present illness:
The patient was apparently asymptomatic 4 days back then he developed fever associated with chills.
- Shortness of breath since 1 day
On 20/12/2021, in the morning the patient lost consciousness for which he was taken to a local hospital and then was referred to Kamineni for further treatment.
He is a schizophrenic patient.
The patient's daily routine is to wake up at 6AM daily, goes for a walk, has lunch at 1-2 PM , goes for a walk again at 6 PM and has dinner at around 9PM, goes to sleep at 10-11 PM.
Past history:
The patient is not a known case of Hypertension, asthma, tuberculosis, diabetes mellitus, epilepsy.
H/O schizophrenia diagnosed at 8 years of age.
Personal history:
- The patient has no loss of appetite
- He takes mixed diet
- No sleep disturbances
- Consumes alcohol occasionally
Family history:
There are no similar complaints in the family.
Treatment history:
The patient is under medication [Olanzapine] for schizophrenia since 17 years.
Not allergic to any known drugs.
General examination:
The patient is conscious, coherent, uncooperative at the time of examination.
- No Pallor
- No icterus
- No cyanosis
- No clubbing of fingers and toes
- No lymphadenopathy
- No pedal edema
Vitals : temperature - afebrile
Pulse rate - 90 beats/ min
Respiratory rate - 20 cycles per min
BP - 130/90 mmHg
Systemic examination :
CVS:
Inspection - chest wall is bilaterally symmetrical
No precordial bulge
- No visible pulsations, engorged veins, scars, sinuses
Palpation - JVP is normal
Auscultation - S1 and S2 heard
RESPIRATORY SYSTEM
- Position of trachea is central
- Bilateral air entry is normal
- Normal vesicular breath sounds heard
- No added sounds
PER ABDOMEN :
Shape of the abdomen: scaphoid
- abdomen is not tender
- bowel and bladder sounds heard
- no palpable mass or free fluid
CNS:
- Patient is conscious
- Speech is present
- Reflexes are normal
Investigations:
Urine for ketones= +ve
Clinical urine tests:
Albumin : 2+
RFT:
Creatinine: 0.6
Urea: 27
Random blood sugar: 352
Na+ : 144
K+: 4.7
LFT:
Total bilirubin(TB): 0.65
Direct bilirubin(DB): 0.18
Aspartate aminotransferase(AST): 28
Alanine aminotransferase(ALT): 19
Alkaline phosphatase: 128
Total protein: 5.7
Albumin : 2.7
Diagnosis:
Diabetic ketoacidosis with HbsAg +ve
Treatment:
1) IVF- NS, RL @125ml/ hr
2) INJ. HAL 2ml IN 39 ml NS @5ml/ hr
3) INJ 5% D@ 75 ml / hr( only if GRBS<200 mg/dl)
4) INJ MONOCEF 1mg IV/BD
5)INJ NEOMOL 1 gm IV /SOS
6)TAB PCM 650 mg PO/ TID
7) TAB OLANZAPINE 10mg PO/OD
8)GRBS- hourly
9)TEMP CHARTING 4th hourly
10) I/O CHARTING
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