20 year old male with uncontrolled sugars

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This is a case of 20 year old male came with cheif complaint of weight loss of nearly 7 kgs (73kgs to 67 kgs ) within 1 month,polydypsia since 6 months 

History of present illness:- 

Patient was apparently asymptomatic 1 month back then he noticed gradual loss of weight nearly 7 kgs ( unintensional - from 73 kgs to 67 kgs) in a span of 1 month.He had h/o polydypsia since 6 months(drinks 7 to 8 liters of water per day).H/0 polyuria,delayed wound healing present .Tingling sensation of fingers of lower limbs.No h/o numbness or loss of sensation.No h/o fatigue,giddiness.No h/o fever,burning micturition.

Past history:-

K/c/o type 1 DM since 2 years( on inj.HAI 40U inj.NPH 40 U ).H/o fulminant hepatic failure a year back and h/o CVA 1 yr back .Not a known case of Htn,thyroid,TB,epilepsy,asthma,CAD.

Personal history:-

Mixed diet

Sleep and apettite normal

Bowel and bladder regular

No addictions

No known allergies

Family history:-

Not significant 

GENERAL EXAMINATION:

-  Patient was examined after taking his consent 

-  Patient is conscious , coherent , cooperative , well oriented to time , place and person 

-  He is moderately built and nourished 

-  No signs of pallor , icterus , cyanosis , clubbing , oedema , lymphadenopathy 

His vitals: 

Temperature : afebrile

BP : 120/80 mm HG 

Pulse rate : 78 / min 

Resp.rate : 16 cpm

Grbs:160 mg/dl 

Systemic Examination:

CVS- S1 S2 heard,no murmurs present.

RS - bilateral Air entry present

Normal vesicular breath sounds heard

Per Abdomen : soft , non tender 

CNS :no focal neurologocal deficits 

Investigations

Plbs: 403 mg/dl

Fbs:- 222mg/dl

Sr.creatinine: 0.8 mg/dl

HbA1c: 7.5 %

Diagnosis:

Uncontrolled type 1 Diabetes mellitus 

50 year old with abdominal pain

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 box

CASE:

This is a case of 50 yr old male farmer came to Opd with chief c/o abdominal pain since december 4th 2022.

HOPI :

Patient was apparently asymptomatic 2 months back.Then he developed abdominal pain after consumption of food on 4th december 2022 in epigastric region and left iliac region.The pain is squeezing type,non radiating,increasing after consumption of food,lasts for about 20 to 30 minutes and relieves on its own,associated with abdominal bloating.

No h/o belching

No h/o regurgitation,

No h/o vomiting,

No h/o loss of apettite,

no h/o diarrhoea or constipation.

No h/o fever,

no h/o blood in stools,

no h/o SOB.

No h/o burning micturition

PAST HISTORY:

No similar complaints in the past.Not a known case of Htn,DM2,TB,Asthma,epilepsy,CVA,CAD.

PERSONAL HISTORY:

Mixed diet

Sleep and apettite normal

Bowel and bladder regular 

Addictions:- known smoker since 20 yrs 

                      smokes 8 to 10 cigarettes/                             day 

                      Occasional drinker 

                      Chews betel nut and khaini 3                         times/day 

No allergies 

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

-  Patient was examined after taking his consent 

-  Patient is conscious , coherent , cooperative , well oriented to time , place and person 

-  He is moderately built and nourished 

-  No signs of pallor , icterus , cyanosis , clubbing , oedema , lymphadenopathy 

His vitals: 

Temperature : afebrile

BP : 120/80 mm HG 

Pulse rate : 78 / min 

Resp.rate : 16 cpm

Grbs:103 mg/dl

Systemic Examination:

GIT examination:-

Inspection

Oral cavity:-No dental caries,Staining of teeth seen

Abdomen:- 

Scaphoid shaped,

Umbilicus centrally placed and inverted,

No visible scars and sinuses,

No visible dilated veins,

No visible peristaltic movements or pulsations.

All quadrants move equally with respiration

Palpation:-

Done on supine position

No local rise of temparature 

No tenderness/rigidity /guarding

No hepatomegaly 

No sleenomegaly 

No other palpable mass felt 

Percussion:-

Tympanic note heard

Auscultation:-

Bowel sounds:- 8/ minute

Respiratory system Examination:-

Bilaterally symmetrical chest,

Chest movements with respiration are equal on both sides

Normal vesicular breath sounds heard

CVS examination:-

S1 S2 heart sounds heard

CNS examination:-

No focal neurological deficits

Investigations:-

USG abdomen:

Hemogram:-

Diagnosis:-

Solitary liver abscess(37mm×23mm heteroechoic solid lesion in segment 4B of liver)

51 year old with fever

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 and treatment plan "

51 YR OLD MALE WITH FEVER AND BODY PAINS SINCE 5 DAYS 

A 51 yr old male who is an agricultural labourer came to OPD with 

CHIEF COMPLAINTS : 

- Fever since  5 days 

- body pains since 5 days 

- loss of appetite and burning micturition since 5 days 

 - reduced appetite since 5 days 

HISTORY OF PRESENT ILLNESS: 

- Patient was apparently asymptomatic 5 days back , he then developed fever , intermittent in nature .Fever is usually low during day time , it later increases during night time , high grade associated with chills and rigors . Patient consulted a local RMP and took injections and used Dolo for fever . Fever relieved on taking antipyretic , again recurs .

- Fever is associated with intermittent episodes of headache , associated with retroorbital pain .

- Reduced appetite and  since 5 days .

- patient had intermittent dry cough for 3 days 

- he complaints of burning micturition and rescued urine output since 5 days .

- No H/O SOB , cold , nausea , vomitings , palpitations, 

Daily routine : 

 Pt wakes up at 5:30 am , he works as an agricultural labourer since 20 yrs , he has tea  breakfast around 7:30 am and goes to work in farm by 8 , at around 1 pm he has lunch ( usually rice ) , comes back home by 6 pm and relaxes , watching TV , completes dinner by 8:30 pm and sleeps by 9 pm

PAST HISTORY :

Not a K/C/O DM, HTN , ASTHMA, EPILEPSY , TB , CAD

H/O hydrocele surgery 20 yrs back 

FAMILY HISTORY : Not significant

 

PERSONAL HISTORY : 

Diet - mixed 

Appetite - reduced 

Bowel movements - regular , bladder movements - reduced 

Sleep - adequate 

Addictions : occasionally consumes toddy 

Allergies : Nil 

GENERAL EXAMINATION :

-  Patient was examined after taking his consent 

-  Patient is conscious , coherent , cooperative , well oriented to time , place and person .He is moderately built and nourished 

-  No signs of pallor , icterus , cyanosis , clubbing , oedema , lymphadenopathy 

His vitals: 

Temperature : afebrile

BP : 120/80 mm HG 

Pulse rate : 78 / min 

Resp.rate : 16 cpm

GRBS : 275 mg/dl

Systemic Examination:

CVS- S1 S2 heard,no murmurs present.

RS - bilateral Air entry present

Normal vesicular breath sounds heard

Per Abdomen : soft , non tender 

CNS :higher mental functions : normal 

Reflexes : 

MOTOR-: normal tone and power 

reflexes:

             RT      LT

Biceps ++        ++

Triceps ++          ++

Supinator ++.      ++

Knee        ++          ++

Ankle  ++             ++

Investigations:

ECG 

USG Abdomen 

Chest X Ray 

CUE 

RBS 

LFT

RFT 

Hemogram 

PROVISIONAL DIAGNOSIS:

VIRAL PYREXIA WITH THROMBOCYTOPENIA 

Management:

- Nebulisation  with salbutamol 4 respules IV/ stat

- IV fluids NS , RL @ 100 ml / hr 

- Tab . Dolo 650 mg PO / TID 

- Inj .Neomol 1 gm IV /SOS if temp > 101 F

- inj .Optinueron 1 amp in 100 ml NS PO/OD 

- syp .Citralka 10 ml PO /TID 

- plenty of oral fluids 

- strict I/O charting

- Vitals monitoring 6 th hrly

- temperature charting 4 th hrly