54 Y/M with vomitings, SOB, fever

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.    

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment plan

26 NOVEMBER 2023

Patient came to causality with complaints of

Fever since 5 days

SOB since 5 days

Vomiting for 3 days

The patient was apparently asymptomatic 5 days back then he developed fever, high grade, not relieved with medication , associated with chills and rigors.

SOB since 5 days, grade III , no orthopnea , pnd.

Also presents with vomitings since 3 days, non bilious, non blood stained , watery, 2-3 episodes.

Ulcer over left foot,since 4 months, associated with edema of foot, 

H/o abscess drainage???

New bleb notes since 2 days.

K/C/O DM II since 14 years, on Metformin 500 mg and Glimiperide 1 mg BD

K/C/O Hypertension since 20 yeats , on Amlodipine 5 mg.

Patient is a vegetarian since childhood.

No addictions

No allergies

Sleep adequate

Regular Bowel and bladder

Decreased appetite

Family history-

Both of the parents mother and father had diabetes.

Father was on medication.

No Pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Edema + left foot

Upto ankle

Vitals

Afebrile

BP - 80/60 mm Hg

PR- 104 bpm

RR- 18 cpm

Systemic examination

CVS- S1 S2 +

RS- BAE+

CNS- NFND

P/A - Soft, Non tender 

Investigations

Rbs- 311 mg/dl