36 year old with starvation ketoacidosis





This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect6current best evidence based input
This Elog also reflects my patient centered online learning portfolio.
Your valuable inputs on 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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever




Under the guidance of 

Dr. Vinay PGY3

Dr.Venkat Sai PGY1



This a case of 36 year old patient admitted with cheif complaints of

1.SOB grade 2 to3 since 3days

2. Dark colored stools since 3days

3. Decreased Appetite since 3days

4. Decreased urine output 


HOPI- 36 year old male was apparently asymptomatic 2months back then he developed complanits of generalized edema and facial puffiness associated with decreased urine output for which he sought  medical help and was found to have dilated chamber of heart and  hypokinesis on 2d ECHO and was advised for alcohol abstinence.He stopped taking alcohol since then.Since 3days he had symptoms of SOB on exertion and stopped taking food because of abdominal tightness/bloating sensation and also passing black colored stools associated with decreased urine output which was progressed to SOB grade 4


PAST HISTORY 

Not a known case of DM/HTN/TB/CAD/ Epilepsy/Asthma 


PERSONAL HISTORY 

DIET- Mixed 

APETITE- Normal 

SLEEP-Adequate 

BOWEL AND BLADDER MOVEMENTS - Regular 

ADDICTIONS -none 


FAMILY HISTORY 

Not significant 


GENRAL EXAMINATION

The patient is coherent, conscious,cooperative well oriented to time place and person 

He is moderately built and nourished 

PALLOR -absent 

ICTERUS -absent 

CYANOSIS -absent 

CLUBBING -absent 

EDEMA -Feet grade1  (pitting type)

LYMAPHDENOPATHY-Absent











VITALS 

TEMP-103F

PR-92bpm

RR -18 cpm

BP-130/80

Spo2-98


SYSTEMIC EXAMINATION 

CVS-S1S2 heard 

CNS-Higher mental functions intact 

PA-Soft and non tender 

RS- BAE+


Diagnosis-

Starvation Ketoacidosis (Resolved) with

  Right heart failure secondary to Alcoholic   

   DCMP

    With ALCOHOLIC STEATOHEPATOSIS


 Investigations


14/9/22







15/9/22








16/9/22



 


17/9/22





19/9/22





TREATMENT:-

1.InJ thiamine 100 mg/IM/TID

2.Tab lasix 80mg /Po/TID

3.Tab Met-Xl 25mg/PO/OD

4.Syp CREMAFINE

5.INJ Buscopan/IM/stat


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