54M with fever and SOB

Hello all this is G Jagadeesh,a eight semester student.This E Log depicts the patient centered approach to learning  

This is an an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

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

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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS 

 A 54 year old male patient came to medicine OPD with chief complaints Of

1) Fever since five days

2) SOB since five days

3) Vomiting since three days

History of presenting illness

The patient was apparently Intermatic five days back then he developed fever, which is of high grade associated with chills and rigors and not relieved on medication. 

Then he had SOB since five days grade 3, There is no history of orthopnea And paroxysmal Nocturnal dyspnoea

He also had 2-3 episodes of vomiting since three days which are non-bilious , non-blood stain and watery. 

There is no history of cough

No H/o Loose stools

No H/o Burning micturition

Past history

He is a K/C/O D M Type 2 since 14 years and he’s on metformin 500 mg and glimiperide 1mg BD

He is a K/C/O HTN Since 20 years and on amlodipine, 50mg

He had a ulcer on the left foot since four months which is associated with idiom of the food and there is a history of abscess drainage

There is a new bleb visible since two days

N/K/C/O asthma,epilepsy,CAD and CVA

Personal history

He’s a vegetarian since childhood

Decreased appetite

Bowel and bladder movements are regular

Sleep is adequate

No Addictions

No allergies

Family history

Both his parents had diabetes

General examination

Patient is conscious, coherent, cooperative

Moderately built and moderately nourished

There are no signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy 

Edema present in left foot

Vitals

Blood pressure-120/80mm Hg

Pulse rate-98 bpm

Respiratory rate-18cpm

Temperature chart

Systemic examination

CVS

S1 and S2 heard 

No murmurs heard

Respiratory system

Inspection

Chest moving equally bilaterally on respiration

No visible pulsation no engorged veins

No scars and sinuses

Palpitation 

Trachea central

Bilateral equal chest movements

Tactile vocal fremitus equal in both side lung fields

Percussion 

Resonant in all fields

Auscultation 

Clear in all fields

NVBS heard

Per abdomen examination

Soft and non tender

No organo megaly 

CNS

Higher mental functions normal

Cranial nerves normal

Sensory system

Fine touch normal

Crude touch normal

Vibration sensation 

Motor system

Tone normal 

Power 

Biceps 5/5

Triceps5/5

Quadriceps5/5

Gluteus maximus 5/5

Reflexes 

Biceps ++

Triceps++

Knee jerk ++

Ankle ++

Cerebellar signs negative

Meningeal signs negative

Skull and spinal cord normal

Diagnosis 

Diabetic foot