Hi, I am Soumyadeep Biswas a medical student . This is an E-Log, that depicts the patient centered approach for learning medicine .This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post . Hope you learn valuable information after giving it a good read !
OSCE CASE QUESTIONS: https://127soumyadeepbiswas.blogspot.com/2023/12/osce.html
A 65 year old male was brought to casualty with
CHIEF COMPLAINTS
Fever since 4 days
Breathlessness since 1 day
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 10 days back when he developed cold and cough with expectoration which is greenish and mucoid no aggravating or relieving factors. Now the expectoration has decreased.
Then developed fever 4 days back which is insidious in onset gradually progressive high grade, continuous and not associated with chills and rigor for which they took medication from a RMP but again appeared.
Patient complained of increased urine passage since last 7days at night (4-5times)
Complaints of decreased appetite since 4days
H/o nausea since 4 days but no vomiting
Patients complaints of dehydration since 4days
Complaints of shortness of breath since four days which was initially grade 2 which now progressed to grade 4 since last night.
No H/o decreased urine out put, pedal edema, loose stools
DAILY ROUTINE
He is a shopkeeper by occupation according to the attender his daily routine is as follows
6 am: takes a cup of tea with sugar
6:30 am: he opens his shop
If he takes a breakfast it's b/w 7-7:30 am
9 am: takes a cup of tea with sugar
11 am: bathes and goes to his shop again
12:30 pm: he eats his lunch
4:30-5:30pm: he again consumes rice
6:00 pm: takes a cup of tea w sugar
7:30 pm: takes his dinner which consist of rice
9 pm: he sleeps
PAST HISTORY
N/K/C/O DM, HTN, TB, Epilepsy, CVA, CAD
Complaints of pain in bilateral knee joints for which he takes NSAIDS when pain increases.
H/o Surgery for right tibial fracture 5 years back
PERSONAL HISTORY
Diet : Vegetarian
Appetite : Normal before 3 days
Sleep: adequate
Bowel and bladder : Normal
Addictions : used to smoke but stopped 5 years back
FAMILY HISTORY
Not significant
GENERAL EXAMINATION
Patient conscious and coherent not co-operative
VITALS
Pulse : 98bpm
RR : 21 cpm
BP : 90/60 mm Hg
Temp. : 99°F
SpO2 : 96%
SYSTEMIC EXAMINATION
CVS : S1, S2 hear, no thrills and murmurs
Respiratory system: On inspection:- normal shaped chest, trachea appears to be in centre, no scars and sinuses present,abdomino thoracic type of respiration, normal respiratory movements present
On palpation:- all inspectory findings are confirmed on palpation.
On percussion:- right left
Infraclavicular resonant resonant
Mammary dullnote. resonant
Axillary. resonant resonant
Infraaxillary. dullnote. resonant
Suprascapular. resonant. resonant
Infrascapular. dullnote resonant
Upper, mid, lower. resonant. resonant
Interscapular
On auscultation:- normal vesicular breath sounds heard and decreased breath sounds in right inframammary,infra axillary,infrasacpular areas.
Dysnea, wheeze, rales and ronchi - absent
Abdomen: scaphoid shaped, soft and diffuse tenderness
CNS
Right Handed person.
HIGHER MENTAL FUNCTIONS:
Conscious, oriented to time place and person.
speech : normal
Behavior : normal
Memory : Intact.
Intelligence : Normal
Lobar Functions :
No hallucinations or delusions.
MOTOR EXAMINATION:
Right Left
UL LL. UL LL
BULK Normal Normal Normal Normal
TONE Normal Normal Normal Normal
POWER 4/5, 4/5 4/5 , 4/5
SUPERFICIAL REFLEXES:
R. L
CORNEAL present present
CONJUNCTIVAL present present
ABDOMINAL present
DEEP TENDON REFLEXES:
R L
BICEPS 2+ 2+
TRICEPS 2+ 2+
SUPINATOR 2+ 2+
KNEE. 2+. 2+
ANKLE 2+. 2+
SPINOTHALAMIC SENSATION:
Crude touch
pain
temperature
DORSAL COLUMN SENSATION:
Fine touch
Vibration
Proprioception
CORTICAL SENSATION:
Two point discrimination
Tactile localisation.
steregnosis
graphasthesia.
INVESTIGATION
PROVISION DIAGNOSIS
? Diabetic ketoacidosis secondary to respiratory disease
TREATMENT
2/12/2023
1) NBM until further orders
2) IV Fluids NS @ 100ml/hr
3) Inj. PIPTAZ 2.5gm IV/TID
4) Inj. LINEZOLID 600mg IV/BD
5) Tab. AZITHROMYCIN 500mg OD
6) Tab. FLUCONAZOLE 150 mg OD
7) Inj. HOMAN ACTRAPID INSULIN infusion @ 6units/hr
8) Inj. PCM 18g IV/SOS ( if temp. >= 101°F)
9) Inj. LASIX 20mg IV/BD ( if SPB >= 110)
10) IV Fluids - FRUSIDEX @ 50ml/hr
11) Tab. ATORUAS 40mg OD
12) Tab. CLOPITAB - A75/75 OD
13) Inj. PAN 40mg IV/OD
14) GRBS moniter hourly
15) Moniter BP, PR, RR, SPO2 Hourly
8:40 PM
1) Stop insulin infusion
2) Inj. HAI 6U in 500ml DNS over 5hrs
3) Inj. KCL 20mEq in 500 NS over 5hrs
Followed by
4) Inj. KCL 20mEq in 500 NS over 5hrs
5) GRBS moniter hourly
3/12/2023
1) Inj. PIPTAZ 2.25gm IV/TID
2) Inj. LINEZOLID 600mg IV/BD
3) Tab. AZITHROMYCIN 500mg OD
4) Tab. FLUCONAZOLE 150 mg OD
5) Inj. PAN 40mg IV/OD
6) Inj. PCM 1g IV/SOS ( if temp. >= 101°F)
7) Inj. LASIX 20mg IV/BD ( if SPB >= 110)
8) Inj. HOMAN ACTRAPID INSULIN infusion S/L TID according to GRBS
9) Tab. ATORUAS 40mg OD
10) Tab. CLOPITAB - A75/75 OD
11) GRBS moniter 2 hourly
12) Moniter BP, PR, RR, SPO2 2 Hourly
13) Nebulization with IPRAVENT 8th hourly and BUDECORT 12th hourly
14) Inj. KCL 20mEq in 500 NS over 5hrs
15) Tab. FENOFIBRATE 160mg OD
16) Tab. METOPROLOL 25mg OD
17) IV fluid DNS with 6u HAI + 20mEq KCl at 100ml/hr
Comments
Post a Comment