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65 Y/O Pneumonia- AKI - DKA

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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. 


A 65 year old male patient, resident of Thurkapallem, shop keeper by occupation came to the OPD with chief complaints of

Chief Complaints: 
Fever since 6 days 
Breathlessness since 3 days 

History of Presenting Illness: 
Patient was apparently asymptomatic 6 days back, then he developed cold and cough with expectorant (green, mucoid) which has now subsided. 
He developed fever since 6 days, high grade, continuous and not associated with chills and rigour. Relieved on taking medications prescribed by local RMP. 
Complaints of decreased appetite since 4 days.
Shortness of breath since 3 days - Grade 2 

No history of hemoptysis 
No history of tightness in chest 
No history of decreased urine output, pedal edema, lose stools 

Past History: 
Not Known Case Of HTN, DBM, Thyroid, Epilepsy 
Previous Surgical History Right Tibial Fracture 5 years ago 
History of taking NSAIDS for pain in both knee joints. 

Personal History: 
Diet: Mixed 
Appetite: Nil 
Bowel and Bladder Movements: Normal
Addictions: Used to smoke 2 packs/ day but stopped 5 years ago 

Family History: 
No similar complaints 

Dietary History: 

6:00 am - Cup of tea with sugar 
7:30 am - Breakfast 
9:00 am - Cup of tea with sugar 
12:30 pm- Lunch (Rice) 
4:30 pm - (Rice) 
6:00 pm - Cup of tea with sugar 
7:30 pm - Dinner ( Rice) 



General Examination: 
Patient is conscious, coherent, co-operative
Moderately built and nourished 
Pallor present 
No Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema. 


Vitals: 
PR: 118 bpm
RR: 21 cpm
BP: 90/60 mmhg
Temp: 102* 
SpO2: 96% 
GRBS: High 


Systemic Examination: 
CVS: S1 S2 heard, no murmurs detected 

Respiratory:
 
 Inspection: 
normal chest shape,
position of trachea - central
No scars,sinuses,engorged veins
Abdominothoracic type of respiration
NVBS
decreased breath sounds in infra axillary and mammary area
Dysnea, wheeze, rales and ronchi - absent

Palpation :- all inspectory findings are confirmed on palpation. 

Percussion:- right              left              

Infraclavicular       resonant            resonant


Mammary          dullnote.            resonant

                                                
Axillary.               resonant                  resonant 


Infraaxillary.       dullnote.                resonant


Suprascapular.       resonant.            resonant


Infrascapular.           dullnote        resonant


Upper, mid, lower.    resonant.      resonant




Auscultation :- 
normal vesicular breath sounds heard 
decreased breath sounds in right infra mammary, infra axillary, infra scapular areas.



Per Abdomen: 
scaphoid shaped, soft and diffuse tenderness 

CNS: 
Drowsy, rousable
Slurred Speech 
No Neck Stiffness 
Tone: Normal in both limbs 
Power: 4/5 in both limbs 
Reflexes:    Right                             Left
Biceps          ++                             ++
Triceps          ++                             ++
Supinator       +.                              +
Knee              ++.                            ++
Ankle              ++.                            ++
Plantar           Flexor                      Flexor

Cerebellar Examination: Normal 

Provisional Diagnosis: 
Diabetic Ketoacidosis 2* to respiratory disease 



Investigations: 









































Treatment: 


2/12/2023

1) NBM until further orders

2) IV Fluids NS @ 100ml/hr

3) Inj. PIPTAZ 2.5gm IV/TID

4) Inj. LINEZOLID 600mg IV/BD

5) Tab. AZITHROMYCIN 500mg OD

6) Tab. FLUCONAZOLE 150 mg OD

7) Inj. HOMAN ACTRAPID INSULIN infusion @ 6units/hr

8) Inj. PCM 18g IV/SOS ( if temp. >= 101°F)

9) Inj. LASIX 20mg IV/BD ( if SPB >= 110)

10) IV Fluids - FRUSIDEX @ 50ml/hr

11) Tab. ATORUAS 40mg OD

12) Tab. CLOPITAB - A75/75 OD

13) Inj. PAN 40mg IV/OD

14) GRBS moniter hourly
 
15) Moniter BP, PR, RR, SPO2 Hourly

8:40 PM

1) Stop insulin infusion

2) Inj. HAI 6U in 500ml DNS over 5hrs

3) Inj. KCL 20mEq in 500 NS over 5hrs

Followed by 

4) Inj. KCL 20mEq in 500 NS over 5hrs

5) GRBS moniter hourly

3/12/2023

1) Inj. PIPTAZ 2.25gm IV/TID

2) Inj. LINEZOLID 600mg IV/BD

3) Tab. AZITHROMYCIN 500mg OD

4) Tab. FLUCONAZOLE 150 mg OD

5) Inj. PAN 40mg IV/OD

6) Inj. PCM 1g IV/SOS ( if temp. >= 101°F)

7) Inj. LASIX 20mg IV/BD ( if SPB >= 110)

8) Inj. HOMAN ACTRAPID INSULIN infusion  S/L TID according to GRBS

9) Tab. ATORUAS 40mg OD

10) Tab. CLOPITAB - A75/75 OD

11) GRBS moniter 2 hourly

12) Moniter BP, PR, RR, SPO2  2 Hourly

13) Nebulization with IPRAVENT 8th hourly and BUDECORT 12th hourly

14) Inj. KCL 20mEq in 500 NS over 5hrs

15) Tab. FENOFIBRATE 160mg OD

16) Tab. METOPROLOL 25mg OD

17) IV fluid DNS with 6u HAI + 20mEq KCl at 100ml/hr

4/12/23
1) Calcium gluconate 1 amp iv stat
2) inj 25% dextrose + 10 IU actrapid iv stat

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