21/07/2023
Samhita Ghanathay
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54 year old male with Fever, Vomitings and Throat pain.
I've been given this case to solve, in an attempt to understand the topic of "patient clinical data analysis" to develope my competency in reading and comprehending clinical data - including history, clinical findings, investigations - and come up with diagnosis and treatment plan.
Following is a brief about the case,
(History as per date of admission).
CHEIF COMPLAINTS:
A 54 year old male, resident of Yadadri, came with complaints of:
* Fever since 3am in the morning.
* Vomiting since 3am in the morning.
* Troat pain since 7am in the morning.
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 1 month back, then he developed generalised itching of body and then went to RMP, where he advised to stop the night dosage of insulin.
After following the advise, the itching did not reduce, so the patient stopped the morning dosage of insulin without authorised advice from a doctor.
He continued taking the afternoon dosage of Tab.Metformin 500mg PO/OD.
Now, since morning, he developed low grade fever, that was insidious in onset, gradually progressing, not associated with chills or rigor. There were no aggravating or reducing factors.
The fever was followed by 3 episodes of vomiting since 3am in the morning, with previous nights food as contents, non-bilious, non-blood stained, non-projectile, associated with generalised weakness.
He also complaints of mild throat pain after vomiting, since 4am this morning, not associated with aggravating or relieving factors.
No H/O headaches, vision changes, dizziness, seizures.
No H/O SOB, cold, cough, chest pain, palpitations, orthopnea, PND.
No H/O loose stools, burning micturition.
No H/O abdominal pain.
PAST HISTORY:
Daily routine:
The patient works as a construction worker in Yadadri district.
He wakes up at 5:30am everyday and visits his fields around 7am. He returns from the fields around 8am, has some rice for breakfast and takes his insulin shot.
He goes to work and comes back around 1pm for lunch, after which he goes back to work and returns in the evening at about 6pm. He has his dinner by 8pm, takes his insulin shot and sleeps by 10pm.
His routine hasn’t changed in the last day.
The patient is a K/C/O Type II DM, since 4 years.
Medication :
- Used oral hypoglycaemic agents (OHA) for 2 years.
- Shifted to injectable Insulin twice daily.
25units of insulin in the morning
↓
Tab.Metformin 500mg in the afternoon
↓
20 units of Insulin in the night.
* There is no H/O similar complaints in the past.
* Not a K/C/O HTN, TB, Asthma, Epilepsy, CVA, CAD.
* No H/O surgeries in the past.
PERSONAL HISTORY:
* Diet - Mixed
* Appatite - Normal
* Sleep - Normal
* Bowel and Bladder - Normal urination, normal bowel.
* Allergy - None
* Addictions
- Alcohol - about 90ml daily ,since his 20 years.
Last intake about 1 week ago.
FAMILY HISTORY:
No history of similar complaints in the family.
GENERAL EXAMINATION:
The patient is conscious,coherent and cooperative; well oriented to time,place and person.
He is sleeping comfortably on the bed.
He is thinly build and well nourished.
* Pallor - present
*Icterus- absent
*Clubbing-absent
*Cyanosis-absent
*Lymphadenopathy-absent
*Edema - absent
Vitals at the time of admission:
*Temperature - 98.6 F.
*Pulse rate - 140/ minute
*Respiratory rate - 22/minute
*Blood pressure (left arm) - 90/60 mm of Hg
*GRBS - 515mg/dl
SYSTEMIC EXAMINATION:
CVS:
S1 and S2 heard.
No addded thrills or murmurs heard
RESPIRATORY SYSTEM:
Normal vesicular breath sounds heard.
Bilateral air entry present.
ABDOMEN:
non tender
soft
CNS:
Conscious and coherent.
Normal sensory and motor responses.
INVESTIGATIONS :
Serology: negative
RBS - High
Hemogram -
21/07/2023
* Total count - increased
* PCV - decreased
* Impression- Normocytic normochromic blood picture with Neutrophilic Leukocytosis.
22/07/2023
*Hemoglobin - low
* Lymphocytes- low
* PCV - reduced
* Impression - Normocytic, Normochromic anemia
Complete urine examination-
* Albumin +
* Sugars +++
* Pus cells - 3-6/HPF
Renal function tests-
21/07/2023 at 3pm
* Urea, Creatinine, Uric acid - increased
* Potassium- increased
21/07/2023 at 11pm
Liver function tests-
* Total and Direct Bilirubin - increased
* Alkaline Phosphate - increased
ABG-
21/07/2023 at 3pm
Compensated Metabolic Acidosis
21/07/2023 at 11pm
22/07/2023 at 5:30am
Urine Osmolality- Increased.
Urine for ketone body- positive
ECG-
Chest X-Ray-
ECG
2D Echo
PROVISIONAL DIAGNOSIS:
The patient is suffering from uncontrolled sugars ?DKA ?HHS with pyrexia ?viral, with K/C/O DM II since 4 years.
TREATMENT:
21/07/2023:
1.
IV fluids - NS 2 . Bolus at 100ml/hour
↓
Inj. HAI 6units IV stat.
↓
Inj. HAI 6 units IV stat.
↓
Inj. HAI 1ml in 39ml NS, at 6ml/hour.
(Increase according to GRBS)
2. Monitor GRBS hourly.
DISCUSSION:
Faculty 1-
Share the entire grbs trends since admission along with the interventions given for it (along with other soap details in the fever chart) and you will understand why.
21st and 22nd 👆🏼
22nd and 23rd
23rd
25/07/23 :
4:30AM - 94mg/dl - 5U HAI + 5NPH ( Took Ragi Java )
8AM - 36mg/dl - Took Dosa
11AM - 158mg/dl - 6U HAI ( Took Rice )
4PM - 148mg/dl - 6U HAI + 4U NPH ( Took Rice )
26/07/23 :
7:30AM - 90mg/dl - 6U HAI + 4U NPH ( Took Jonna Gatka )
10:30AM - 322mg/dl
2PM - 220mg/dl - 6U HAI + 4U NPH ( Had Rice )
5PM - 155mg/dl
8PM - 45mg/dl ( Had Gatka )
10PM -213mg/dl
27/07/23
8AM - 383mg/dl - 8U HAI +6U NPH ( Had Gatka )
10AM - 427mg/dl
2PM - 290mg/dl - 8U HAI ( Had Rice + Curry )
4PM - 161mg/dl
8PM - 380mg/dl 8U HAI + 6NPH ( Had Roti & Curry )
10PM - 154mg/dl
2AM - 53mg/dl ( Had Roti + Curry )
28/07/23
8AM - 345mg/dl - 10U HAI+8UNPH ( Had Gatka+Curry )
10:40AM - 300mg/dl
2PM - 86mg/dl - 10U HAI ( Had Rice )
4PM - 145mg/dl
8PM - 160mg/dl - 8UHAI + 4NPH ( Had Rice + Curry )
10PM - 89mg/dl ( Had 5 Biscuits )
3AM - 62mg/dl
29/7/23
8AM - 272mg/dl - 10U HAI + 8U NPH ( Had Gatka + Curry)
10AM - 278mg/dl
2PM - 34mg/dl - 6U HAI ( Had Rice + Curry )
4:30PM - 118mg/dl
8PM - 128mg/dl - 6U HAI ( Had Rice + Curry )
10:30PM - 83mg/dl ( Had 10 Biscuits )
30/7/23
8AM - 33mg/dl ( Had Gatka )
10AM - 424mg/dl
2PM - 302mg/dl - 4U HAI ( Had Rice + Curry )
5PM - 439mg/dl - 6U HAI
8PM - 366mg/dl - 4U HAI ( Had Rice + Curry )
31/7/23
8AM - 518 mg/dl - 10U HAI ( Had Gatka)
11:20AM - 342 mg/dl
2:30PM - 22mg/dl ( Had Rice + Curry )
8PM - Did not Check Sugars - 5U HAI ( Had Rice + Curry )
1/8/23
8:52AM - 65mg/dl ( Had Gatka + Dal )
11AM- 309mg/dl
2:24PM - 291mg/dl - 4U HAI ( Had Rice + Curry )
8:30PM - 271mg/dl - 8U HAI ( Had Rice + Curry )
2/8/23
5 pm : 533 mg/dl ( 10U HAI )
9 PM : 129 mg /dl ( 4 U HAI )
3/08/23
8am : 588mg/dl -10IU HAI given ( had dosa)
1 pm : 315 mg/dl - 4 IU HAI given ( had rice and curry)
4 pm : 199 mg /dl
7:30 pm : 364 mg/dl -
10:20 pm : high ( 4 IU HAI given )
4/08/2023
8 am : 505 mg /dl - 8 IU HAI is given ( had dosa )
10am : 209 mg/dl
1 pm : 358mg/dl - 6 IU HAI given ( had rice and curry)
4 pm : 290 mg /dl
7:50 pm : 370 mg/dl - 6 IU HAI ( Had gatka )
05/08/23
8am : high ( given 10 IU HAI ) ( had gatka )
11 am : 527 mg/dl
( Lab : 483 mg/dl )
1 pm : 292 mg/dl given 6 IU HAI ( had gatka )
( Lab : 279 mg/dl )
3 pm : 230 mg/dl
( Lab :244 mg /dl )
7 pm : 319 mg/dl given 8 IU HAI ( had rice and plum fruits )
( Lab : 327 mg/dl )
10 pm : 131 mg/dl
( Lab : 138 mg /dl )
2am : 258 mg/dl
( Lab : 204 mg /dl )
06/08/23
8am : 600 mg/dl ( given 10 IU HAI ) ( had idli with chutney)
Lab : 596 mg /dl
11 am : 432 mg/dl
12:30 pm : 262 mg/dl given 6 IU HAI ( had gatka and plum fruits )
3 pm : 274 mg/dl
7 pm : 404 mg/dl given 8 IU HAI and 4IU NPH ( had roti and apple )
10 pm : 258 mg/dl
2 am : 102 mg/dl
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