General medicine prefinals exam case

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment"

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: 



Clinical images










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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