147 Viswanath Garudadhri GM, ?COMMUNITY ACQUIRED PNEUMONIA


Viswanath Garudadhri 


Roll no -147 , 3rd sem 




 Under the guidance of Dr. Manasa (intern) 

  This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.

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 come up with a diagnosis and treatment plan. 


CASE SCENARIO


     A 55 yr old male came to casuality with cheif complaints of fever since 6 days and inability to walk since 4 days.


HISTORY OF PRESENTING ILLNESS


Taken to local hospital 2 days ago. Found to have GRBS around 30 and ketone bodies found in urine.

Low grade intermittent fever since 5-6 days

Generalized body weakness and unable to walk since 4 days .


Was given treatment there and brought to our hospital for further treatment.


No other complaints 


HISTORY OF PAST ILLNESS 


Type 2 DM present

    Not a k/c/o Asthma, Epilepsy, TB, HTN



TREATMENT HISTORY 

Taking OHA for diabetes since 7yrs



PERSONAL HISTORY


 Married

Occupation - farmer

 Normal appetite

Bowel - regular

Micturition- normal

 No known allergies

Addictions

Occasionally consumes alcohol and smokes tobbaco since 20 years.


FAMILY HISTORY

Diabetes - No

Asthma - No

Hypertension - No

Heart disease - No

Stroke - No

Cancer - No

Tuberculosis - No











GENERAL EXAMINATIONS


 No-

Icterus/Cyanosis/Lymphadenopathy/Malnutrition


Temperature -100F

Pulse rate - 130beats /min

Bp - 80/50

SpO2 - 96%

GRBS - 425 mg%


SYSTEMIC EXAMINATION



CVS:  


No Thrills

Cardiac Sounds - S1, S2 +

No cardiac murmurs




RESPIRATORY SYSTEM: 


Dyspnoea - No

No Wheezing

Position of Trachea - central

Vesicular sounds 




ABDOMEN:


Shape - Scaphoid

No palpable mass

Bowel sounds- present



CNS:


Level of consciousness - conscious

Glassgow scale -E4 V5 M6



GAIT, MUSCULO SKELETAL SYSTEM, SKIN, ENT, HEAD AND NECK - NORMAL 

PUSTULAR LESIONS SEEN IN ORAL CAVITY

PRESENT ON HARD PALATE AND OROPHARYNX


Investigations




Ultrasound



Investigation reports on 27/8


Serum creatinine - 1.5mg/dl

SGPT -40 IU/L

SGOT  - 24 IU/L

ESR - 100 mm/first hr

ALKALINE PHOSPHATASE - 279 IU/L

BLOOD UREA - 158 mg/dl

SERUM PROTEIN - 6.2g/dl

RBS - 424mg/dl




Investigation reports on 29/8


HB1Ac - 7.4%

SERUM CREATININE -2 mg/dl

BLOOD UREA - 180 mg/dl


Provisional diagnosis


?community acquired pneumonia 

Type-2 DM with uncontrolled sugars


Treatment


IV fluid 20 ns  IV/BOLUS

IVF  0.9% NS 100ml/hr

Inj Pan 40mg  IV/od

Inj ZOFER 4 mg IV/sos

Inj HAI  every 6hrs

Inj NPH. Every 12hrs

Inj Optineuron 1amp in 100ml ns IV/OD

Tab Dolo 650mg  TID










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