GENERAL MEDICINE ONLINE CASE DISCUSSION.

A 19 YEAR OLD MALE WITH VOMITING AND SHORTNESS OF BREATH.

Name: Y.Navya sahithi reddy 
Roll no: 146
March 29.

This is an online E-Log book to discuss our patient's de-identified 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 these patient's clinical problems with collective current best evidence-based inputs. This E-log also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome.

A 19Y old male, resident of Miryalguda studying degree first year came to the OPD on 24th March 2022 with
 chief complaints of:
1)Vomitings since 2 days
2)Shortness of breath since afternoon on 24th March 2022.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 and half year ago, then he developed polyuria,polydipsia,nocturia and diagnosed with diabetic type 1 MISC  post cOVID  and during hospital stay,on the day 5 he went to the coma for 7 days and he recobered and discharged after 20 days .. about 4 months ago he developed vomitings ,which was non projectile type,food and water as content. since  2days vomiting 10 episodes in 2days, associated with nausea and abdominal discomfort after episode of vomiting, non projectile, non bilious and had food particles as contents, not blood stained.
Patient have h/o outside food consumption.
Shortness of breath at rest since afternoon,24/03/2022 
No aggrevating and relieving factors.
No  h/o fever, loose stools, cough and cold, pain abdomen, burning micturition. 

PAST HISTORY:
No history of Hypertension, Asthma, Tuberculosis.

FAMILY HISTORY: 
Insignificant.

PERSONAL HISTORY:
Daily routine
8am - wakes up9am- breakfast10am to 1pm goes to college2pm- Lunch3pm to 6pm- goes out with friends8 pm- dinner9pm- sleep

Diet: Mixed
Appetite: adequate
Sleep: adequate
Bowel and bladder: regular
No Addictions and allergies
No surgical history
Treatment history: INSULIN 52-26-52.

GENERAL EXAMINATION:

The patient was examined in a well-lit room after informed consent was taken.
He is conscious, coherent, cooperative, well oriented to time, place and person. He was well nourished and well built.
Weight: 75 kgs
Height: 167cms
BMI: 27.7

No Pallor, Icterus, Clubbing, Cyanosis, Koilonychia, Lymphadenopathy, Edema.
VITALS:
Temperature: afebrile
PR: 76bpm
RR: 18cpm
BP: 120/80 mmHg
SpO2: 96% on RAG
RBS: 157mgdL on 28/03/2022

SYSTEMIC EXAMINATION:

PER ABDOMEN
Inspection:

Shape of abdomen - distended
 Umbilicus- transverse slit
Abdominal movements- equal in all quadrants with respiration, 
no visible peristalsis.
Skin- normal
 no scars and sinuses, no engorged veins.

Palpation:

Light palpation- all quadrants are normal
 no pain
Deep palpation- lipodystrophy felt on right iliac fossa 
LIVER: not enlarged
SPLEEN- not enlarged
KIDNEYS - bimodal palpable kidneys 

PERCUSSION: no shifting dullness.

AUSCULTATION: Bowel sounds are heard and are normal.No bruit

CVS:     S1 and S2 heard, no murmurs

CNS:    NAD
RS:       BAE+

INVESTIGATIONS:

SERUM ELECTROLYTES
RANDOM BLOOD SUGAR

BLOOD UREA

HbA1C

HEMOGRAM

LIVER FUNCTION TEST

PHOSPHORUS

SERUM CREATININE

FASTING BLOOD SUGAR
URINE KETONE BODIES
HEMOGRAM
ECG
USG ABDOMEN
Impression: Grade 1 fatty liver.

PROVISIONAL DIAGNOSIS:
Diabetic ketoacidosis 2° to ? inadequate insulin, ?Acute Gastroenteritis.

TREATMENT:
29/03/2022

IVF - 20 NS, 20 RL @ 100ml / hrInj. HUMAN ACTRAPID 40U in 39ml NS @ 5 ml /hr Inj. PANTOP 40 mg IV  OD Inj. MONOCEF 1gm IV BDInj. ZOFER 4mg IV BD INJ. NEOMOL 1 gm IV SOS ( if temp > 101 F)  Tab. DOLO 650 mg PO SOSInj. 5% dextrose 50 ml / hr ( if GRBS< 250)Strict GRBS, BP charting 


















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