General medicine AMC case
24 year old male with C/C of generalised weakness
3rd March,2022
I have 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 diagnosis with a treatment plan.
March 3rd,2022
A.Bhavani
Roll.no-150
9 th semester
This is an online E log book to discuss our patient’s de-identified health data shared after taking his guardian’s signed informed consent.
A 24 year old, sand contractor by occupation, came with complaints of
- Generalized weakness since 1 week
- Loss of appetite and loss of weight since 1 week.
History of presenting illness
Patient was apparently asymptomatic 1 week back and then developed generalized weakness, loss of appetite and weight loss (approx 2 kgs) for which he came to the hospital and got diagnosed with Diabetes, one day back.
No h/o fever, abdominal pain, vomittings, diarrhoea, chest pain or palpitations.
Patient also complained of increased frequency of micturition since 6 days, he had to wake 3-4 times at night to urinate and passed urine 3 times in the day. Gives history of increased thirst as well.
Patient gives history of one episode of Giddiness 10days and went to local RMP, where they recorded a BP of 180/100 mm Hg, so they gave him injections and tablets(unknown).
Patient has significant alcohol consumption history. He started drinking since the age of 12. He was apparently rewarded for all the effort he put in through day with 1-2 glasses of toddy, by his grandparents. He used to consume one glass approx 2-3 days/week from the age 12-16.
Since 16 years of age to 24 years, he consumed 2 bottles of Toddy everyday and occasionally one bottle of beer as well.
He says he has abstained from alcohol since 3-4 weeks.
No previous hospital admissions.
Past history
Patient’s mother reports that till the age of 5, patient had Shortness of breath and weakness and when they consulted a Doctor, they were told he has a hole in his heart (?PDA).
He didn’t receive any treatment for it neither did he undergo any surgery.
She says it improved with age.
No history of thyroid disorders, epilepsy, TB, CAD.
Family history:
Patient’s father got diagnosed with Diabetes Mellitus and Hypertension 3 years back and is using medication for it.
General examination
Patient is conscious, coherent and cooperative.
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy or oedema of feet.
No Acanthosis nigricans seen.
Redness of eyes present.
Vitals on admission:
Temp: 98.4°F
BP: 150/70 mm hg
PR: 84 bpm
RR: 24 cpm
BP: 150/70mmg Hg
SpO2: 98% on RA
GRBS: 472 mg/dl
CVS examination:
S1 S2 present
No murmurs, thrills.
Respiratory System examination:
Bilateral Airway Entry present.
No wheeze, dyspnoea or adventitious sounds.
CNS:
HMF: intact. Conscious.
Tone: R. L
UL. N. N
LL. N. N
Power: R. L
UL. 5/5. 5/5
LL. 5/5. 5/5
Reflexes: R. L
B. +. +
T. +. +
S. +. +
K. +. +
A. +. +
No cerebellar signs present.
Investigations:
1/3/22
FBS: 357 mg/dl
PLBS: 476 mg/dl
HbA1c: 7.5%
RFT(28/2/22)
Urea: 33
Creatinine: 0.9
Uric acid: 11.1
Calcium: 10.0
Phosphorus: 5.1
Sodium: 135.
Potassium: 4.2
Chloride: 98
Serum electrolytes(1/3/22)
Na: 134
K: 4.1
Cl: 99
CBP(28/2/22)
Hb: 15.2
TLC: 7,700
N: 66
L: 25
E:04
Plt: 3.04 lakhs/cu.mm
Smear:: Normocytic Normochromic
CUE (28/2/22)
Albumin: +
Sugar: ++++
Pus cells: 4-5
Epithelial cells: 3-4
2D ECHO (28/2/22)
No MR/AR/TR
Good LV systolic function
No RWMA
EF: 62%
ECG:
USG ABDOMEN(28/2/22):
Imp: Grade III Fatty liver
ABG: (1/3/22)
pH: 7.343
pCO2: 34.7
pO2: 62.1
HCO3 st: 19.3
Anion gap: 21
High anion gap metabolic acidosis.
ABG(2/3/22)
pH: 7.422
pCO2: 36.4
pO2: 132
HCO3: 24
Anion gap: 3.8
UKB (1/3/22): positive
LFT (1/3/22)
TB: 3.39
DB: 0.82
AST: 39
ALT: 52
Alk P: 190
TP: 7.1
Alb: 4.7
A/G: 206
Serum electrolytes(1/3/22)
Na: 134
K: 4.1
Cl: 99
Chest X Ray:
Based on his ABG and Blood glucose levels, treatment for Diabetic Ketoacidosis was started.
Diagnosis: Diabetic Ketoacidosis with DeNovo detected ?MODY
Treatment:
1. NBM till further orders
2. 1 ml HAI + 39ml NS @6ml/hr
3. IVF NS continuous infusion @200ml/hr
4. GRBS hourly
2/3/22
S:
Complaints of generalized weakness, loss of appetite and uncontrolled sugars
O:
Temp: 98.6 °F
PR: 73 bpm
BP: 140/80 mm Hg
SpO2: 98%
GRBS: 173mg/dl @2ml/hr
Input: 6L
Output: 3L
CVS: S1 S2 +
RS: BAE +
CNS: E4V5M6
ABG(2/3/22)
pH: 7.346
pCO2: 31.0
pO2: 101
cHCO3st: 18.4
AG: 18.5 (2/3/22 at 8AM
AG: 21 (1/3/22) at 8PM
A:
Diabetic KetoAcidosis with de novo detected ?MODY
P:
1.NBM till further orders
2. 1 ml HAI + 39ml NS @6ml/hr
3. IVF NS continuous infusion @200ml/hr
4. GRBS hourly
3/3/22
S:
Complaints of generalized weakness, loss of appetite and uncontrolled sugars(RESOLVED)
O:
Temp: 98.6 °F
PR: 75 bpm
BP: 130/80 mm Hg
SpO2: 98%
GRBS: 109mg/dl @2ml/hr insulin infusion
Input: 3500ml
Output: 1200ml
CVS: S1 S2 +
RS: BAE +
CNS: E4V5M6
ABG(2/3/22)
pH: 7.355
pCO2: 32.8
pO2: 105
cHCO3st: 19.6
AG: 18.5 (2/3/22 at 8AM
AG: 19 (3/3/22) at 8AM
A:
Diabetic KetoAcidosis with de novo detected ?Type I Diabetes Mellitus
P:
1. Allowing soft diet
2. Inj. HAI 10U TID
10U——10U——10U
3. Inj. NPH 15U BD
15U——X——15U
4. GRBS before food and 2hours after food
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