FINAL PRACTICAL SHORT CASE.
This is 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 patients 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 comment box is welcome .
I’ve 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 .
A 46 year old male came to casuality with chief complaints of
-burning micturition since 10days
-hiccups since 3days
-vomiting since 2days (3-4 episodes)
-giddiness and deviation of mouth since 1day.
HISTORY OF PRESENT ILLNESS:
3 days back then pateint complaints of hiccups.
Patient complaints of deviation of mouth and giddiness one day, he was brought to the hospital and his GRBS was recorded to be high for which he was given NPH 10 IU and HAI 10 IU.
No c/o fever/cough/cold/ abdominal pain.
No c/o chest pains/palpitations/syncopal attacks.
10years back patient complained of polyuria after which he was diagnosed with Type 2 Diabetes Mellitus, he was started on oral hypoglycemic agents(OHA), which he took on and off due to financial crisis.
3years back OHAs were replaced by Insulin, he is taking insulin three times a day before food regularly.
3years ago he underwent a cataract surgery in the right eye.
1year ago he had injury to his right leg, which gradually progressed to non healing ulcer extending upto below knee and ended with undergoing below knee amputation due to developement of wet gangrene.
Delayed wound healing was present- it took 2months to heal
Not a k/c/o Hypertension, Epilepsy,Tuberculosis, Thyroid
Not on any medication
No history of blood transfusion
PERSONAL HISTORY:
Appetite : normal
Sleep : Adequate
Bowel and bladder : Regular bowel
Micturition : burning micturition present
Habits/Addiction:
Alcohol-
Not consuming alcohol since 1 yr.
Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
Pulse: 98 bpm
SPO2: 98% on RA
GRBS: 124mg/dl
SYSTEMIC EXAMINATION:
INSPECTION:
Shape – scaphoid
Flanks – free
Umbilicus –central , inverted.
All quadrants of abdomen are moving with respiration.
No dilated engorged veins
No visible pulsations, visible peristalsis and scars.
PALPATION:
No local rise of temperature and tenderness
All inspectory findings are confirmed.
No guarding, rigidity
Deep palpation-
Liver : palpable just below costal margin ( right)
Sleep : not palpable
Kidney : not palpable
PERCUSSION:
AUSCULTATION:
Bowel sounds heard.
CNS:
Higher function test:
Patient is having altered sensorium
Slurred speech
Not Orientated to time place person.
Memory couldn't be elicited as patient is in altered sensorium
Cranial nerves : intact
Motor system :
Upperlimb normal. Normal
Lowerlimb. thigh -N. Normal
Below knee amputated on R side
2. Tone :
Upperlimb. Normal. Normal
Lowerlimb. Normal. Normal
Neck: Normal
Trunk: Normal
Upper limb 5 5
Lower limb 5 5
Right Left
Biceps 2+. 2+
Triceps 2+ 2+
Supinator 2+ 2+
Knee - 2+
Ankle - 2+
Planter reflex Amputated flexion
Right (emphysematous?) pyelonephiritis and left acute pyelonephiritis and encephalopathy secondary to sepsis.
INVESTIGATIONS:
ON DAY OF ADMISSION:
ON DAY 6
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