final practical case long
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 global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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
43 year female came with complaints of pain abdomen & vomitings since 1 day
History of present illness : Patient was apparently asymptomatic 6 yrs back, then had anasarca , went to hospital in hyderabad & diagnosed to have hypothyroidism ( started on tab.THYRONORM 50 micrograms)
& also diagnosed as renal failure & was on TAB.TORSEMIDE 20MG+ SPIRONOLACTONE 50MG
& also DM 2 ( started on inj.MIXTARD )
Currently patient complaining of pain abdomen which is diffuse , intermittent, dull aching pain associated with vomitings, 2 episodes non bilious , non projectile , food as content .
No H/O fever, cold, cough, loose stools, constipation , malena, haematuria
No H/O pedal edema, decreased urine output, facial puffiness,
PAST HISTORY :
Known case of DM 2 since 6yrs ( using INJ.MIXTARD 20U...X....25U)
Hypothyroidism since 6yrs ( TAB.THYRONORM 25microgram)
Not a known case of HTN, bronchial asthma, epilepsy, tb
TREATMENT HISTORY :
1) DM 2 since 6yrs ( using INJ.MIXTARD 20U...X....25U)
2)Hypothyroidism since 6yrs ( TAB.THYRONORM 25microgram)
PERSONAL HISTORY :
Diet : mixed
Appetite : decreased
Sleep : adequate
Bowel & bladder : regular
No known addictions.
FAMILY HISTORY : Not significant
ON EXAMINATION :
Patient is conscious, coherent, cooperative.
Pallor +
Icterus,clubbing, cyanosis , koilonychia, edema are absent
VITALS
Temp- Afebrile
Bp-150/80 mm hg
Pr- 88bpm
Rr-21cpm
Spo2- 99% on RA
Grbs : High
SYSTEMIC EXAMINATION :
RS- decreased breath sounds ,BAE+
Cvs-S1 S2 +,no murmurs heard
P/A - soft, diffuse tenderness +
Cns- no abnormality detected
GCS - 15/15
INVESTIGATIONS : (3/2/22)
ABG :
PH - 7.21
PCO2- 25.8
PO2- 89.2
HCO3- 12
RBS : 560MG/DL
HBA1C : 8.1
HEMOGRAM :
HB: 9.4
TLC : 13,200
RBC : 3.47million/cu3
Urine for ketone bodies : positive
RFT :
serun creatinine : 4.6
Urea : 4.6
Na+ : 131
K+: 4.6
LFT :
SGPT : 125
SGOT : 137
ALP : 372
TP: 5.5
ALB : 2.7
Sr. Amylase : 237
Sr. Lipase : 92
USG ABDOMEN :
1.GB wall edema
2. Mild pleural effusion
3.No ascitis
PROVISIONAL DIAGNOSIS : pain abdomen secondary to uncontrolled sugars with DKA with pancreatitis with AKI on CKD. (CKD secondary to metabolic acidosis ) metabolic acidosis secondary to DKA & CKD with H/o DM-2 , hypothyroidism .
TREATMENT PLAN:
ON 3/2/22
1)IVF – 0.9%NS 1L FOR 1ST hour
1L FOR 2ND hour
1L FOR 3rd hour
2) IVF – 0.9% NS @ 250ml/hr for next 6 hours
3)INJ. HAI – 0.1IU /KG /B.wt IV /STAT
4)INJ.HAI – 1ml in 39ml NS @ 6ml/hr infusion (according to ALGO 1 )
5 INJ. PANTOP 40mg IV/OD
6)INJ.ZOFER 4mg IV/SOS
TREATMENT ON 4/2/22 & 5/2/22
1) IVF – 0.9% NS @ 150ml/hr
2) INJ. PANTOP 40mg IV/OD
3)INJ.ZOFER 4mg IV/TID
4) INJ. METROGYL 500MG /IV / TID
5) INJ. TRAMADOL 1AMP IN 100 ML NS /IV/TID
6)INJ. INSULIN INFUSION WITH 2ML/HR
7)INJ.BUSCOPAN 2CC IV/SOS
8)INJ.LASIX 40MG IV/BD
9) TAB.THYRONORM 50microgram PO/OD
10) PLANNING TO SEND STOOL FOR OVA CYST & CULTURE( i/v/o yellowish green stools )
