A 45 year old male with hypokalemia


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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 diagnosis and treatment plan.

 A 45 year old male resident of cherlapally farmer by occupation came with complaints of pain in the right upper limb near the (shoulder)since 10 days

HOPI

Patient was apparently asymptomatic 2 yrs back.

Then his appetite increased for which he came to our  hospital and diagnosed with Diabetes.

He used oral hypoglycemic agents for the first six months and from past one and half year he is on insulin

History of increased urine output since 2 years

History of weight loss(25 kgs) since 2 yrs

In August 2022  he developed slurring of speech for which he was admitted in our hospital and diagnosed as Urosepsis 

Again in October  she had shortness of breath for which he came to our hospital and 4 sessions of dialysis was done 

Now since 10 days he had pain in the right upper limb and swelling in upper limb since 1 day

On 23 /11/2022 he came to our hospital with complaints of pain in the right upper limb since 10 days and swellingand discharge(serous) in upper limb since 1 day 

No h/o fever vomiting loose stools 

There is h/o difficult in getting up and his sleep is disturbed since 10 days

He was admitted in General surgery and diagnosed with gas gangrene for which Incision and drainage was done under local anaesthesia.

Now he is referred our department as the patient have metabolic acidosis and hypokalemia


DAILY ROUTINE


Wake up in the morning by 4am then he will have milk by 5am and then he eat food (rice)by8am and then he goes for cattle rearing come back by 3pm then he takes some food rest and then he takes food at 6pm and goes to sleep by 7pm

His daily routine  disturb after he developed the illness

PAST HISTORY

No similar complaints in the past 

No history of hypertension Asthma Tuberculosis


Personal history

Diet:mixed 

Appetite: increased

Sleep: disturbed

Bowel (loose stools)and bladder(irregular)

Addictions: Alcohol since 25 yrs (180ml/day)

FAMILY HISTORY:No significant family history

DRUG HISTORY:No history of allergy to any drugs 

GENERAL EXAMINATION

Patient was conscious coherent and cooperative

Poorly  built and nourished  

Pallor present


No Icterus


No cyanosis


No clubbing


No generalized lymphadenopathy


Bilateral pedal edema present


Vitals 


Temp Afebrile 


PR70  bpm


BP 130/70 mm Hg 


RR 16 cpm


GRBS 102mg/dl on 30/11/2022







 









SYSTEMIC EXAMINATION

Respiratory System

Inspection

Symmetrical chest seen


No scars and sinuses 


Trachea is Central in position


Palpation:


Inspectory findings are confirmed 

Expansion of chest is equal in all planes 



Percussion: 


Resonant note present over all lung areas


Ascultation:


Normal vesicular Breath sounds heard. 


PER ABDOMEN 


Inspection: 

Abdomen is flat

No Abdominal distension 

No scars, sinuses, mass visible 

No engorged veins are seen

Umbilicus is central and inverted 

No visible pulsations

Movements are equal over 9 regions during respiration


Palpation:


All inspectory findings are confirmed 


No local rise of temperature


 No Tenderness


No hepatomegaly and No spleenomegaly 

Percussion 

Normal

Auscultation


: Normal bowel sounds heard


No bruit heard


CARDIOVASCULAR SYSTEM EXAMINATION 


Inspection : Bilaterally symmetrical chest present 


No scars, sinuses



Palpation:


Inspectory findings are confirmed


Apex beat normal


On Auscultation : 


S1 S2 heard


No murmurs or additional heart sounds


CENTRAL NERVOUS SYSTEM EXAMINATION 

No focal neurological defecits  

INVESTIGATIONS

On 23/11/2022 








On 1/12/2022









ECG 



PROVISIONAL DIAGNOSIS 

Right upper limb gas gangrene (post op) with hypokalemia 

TREATMENT 

On 1/12/2022

I.MVT 500 ml OD IV

I.meropenem IV BD 

I.Clindamycin IV TID 

I.Astymin IV BD 

Tab Pantop 40 mg peroral OD 

T.Nodosis500 PO OD 

.T.Chymoral peroral OD 

T.Dolo 650 PO OD 

Syrup.Potklor PO OD 

Protein Powder in 1 glass of water

T.Orofer PO OD 

T.Vit c PO OD







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