GENERAL MEDICINE E-Log

 GENERAL MEDICINE E-log 18/08/21

05 K. Neeha sruthi

(OLD BATCH)

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 available 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-centered 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. 

CASE :

A 45 year old man, farmer by occupation presented with the complaints of

Pain abdomen since 3 days

Nausea since 3 days 

Vomiting 1 day back 

HISTORY OF PRESENT ILLNESS :

Since 3 days, he has been experiencing continuous pain abdomen in his epigastrium and left hypochondriac region, which doesn't get relieved on sitting posture but is aggravated on eating food along with this he also has been experiencing nausea. He also had 1 episode of vomiting which was non projectile, non bilious, non blood tinged Vomiting with food content.

PAST HISTORY: 

2 years back - He experienced profuse sweating for which he was taken to a local hospital and was diagnosed to be denovo diabetic and back then his blood sugars were 600mg/dl according to his wife and he was started on Inj Human Insulin.

Over the past 2 years - he got admitted thrice with similar complaints of Pain abdomen and nausea and was diagnosed with acute pancreatitis

1 year back - he had giddiness and fell on his right knee, back then he was taken to a local hospital and was told to have hypoglycemia and his Insulin doses were reduced.

Since the past 1 year: he continued experiencing right knee joint pains for which he paid a visit to multiple hospitals but wasn't relieved of the Pain.

PERSONAL HISTORY:

Patient works as a farmer along with his wife at nalgonda. He has 2 kids. He has been a regular alcoholic since the past 20 years with a daily intake of 90 to 180 ml of whiskey per day. He stopped consuming alcohol 1 month back. He also chews tobacco, atleast 2 times per day.

GENERAL EXAMINATION 

PHYSICAL EXAMINATION:

On presentation to us, he was a thin built man 

Pallor +

PR - 70 bpm

Bp - 110/70mmhg

RR - 18 cpm 

Spo2 - 99%

GRBS - 472 mg/dl

SYSTEMIC EXAMINATION:

Per Abdomen:

Tenderness present in epigastrium and left hypochondriac region 

Cvs - S1,S2+

Lungs - clear on auscultation 

CNS - Normal 

INVESTIGATIONS :

1) ECG.  

     

2) FEVER CHART

3) USG REPORT 

4) HEMOGRAM

5) COMPLETE URINE EXAMINATION

6) URINE FOR KETONE BODIES

 

RADIOMETER ANALYSIS - 16/08/21

BLOOD GAS VALUES

pH - 7.330

pCO2- 19.2 mmHg

pO2-111 mmHg

CALCULATED VALUES

cHCO3- (P,st)c - 14.2 mmol/L

RADIOMETER ANALYSIS-17/08/21

BLOOD GAS VALUES

pH -7.396

pCO2 - 33.6 mmHg

pO2 - 86.6 mmHg

CALCULATED VALUES

cHCO3- (P,st)c - 21.6 mmol/L

SEROLOGY

Rapid HBsAg - NEGATIVE

Rapid HIV 1&2- NEGATIVE 

Rapid anti HCV antibodies- NEGATIVE 

SERUM AMYLASE - 28.2

LIPASE - 14.4

TB-6.06

DB-0.59

ALT-11

ALP- 196

TP-7.1

Ur-25

Cr-0.9

Na+ -136

K+ -3.9

Cl - 98

FASTING BLOOD SUGAR

FBS - 70mg/dl 

POST LUNCH BLOOD SUGAR

GLYCATED HAEMOGLOBIN

HbA1c - 7.6%

DIAGNOSIS:

Diabetic ketoacidosis known case of TYPE-II DM since 2 years, chronic pancreatitis.

TREATMENT:

Day-0

1)IVF- 20NS -100ml/lit

         20RL- 100ml/lit

2)Inj.PAN 40mg IV/OD

3)Inj.Zoffer 4mg IV/TID

4) Inj.Tramadol 50mg/day - 100mlNS

                                              Iv/TID

5) Strict I 10 CHARTING

6)Bp/PR/RR/SpO2: Charting

          GRBS- 2th hrly

7) BUN/PCV monitoring 12th hrly

8) Inj. THIAMINE 10mg in 100ml NS/IV/OD

9) Inj.NAI SE/TID

       8am-2pm-8pm

DAY-1

1)IVF- 20NS -100ml/lit

         20RL- 100ml/lit

2)Inj.PAN 40mg IV/OD

3)Inj.Zoffer 4mg IV/TID

4) Inj.Tramadol 50mg/day - 100mlNS

                                              Iv/TID

5) Strict I 10 CHARTING 

6) Inj. THIAMINE 10mg in 100ml NS/IV/OD

7) INJ.HAI SC/TID 

    8am-2pm-8pm

8)BP/PR/RR/SpO2 CHARTING

                                 4th hrly

      GRBS 4th hrly

DAY -2

1)IVF- 20NS -100ml/lit

         20RL- 100ml/lit

2)Inj.PAN 40mg IV/OD

3)Inj.Zoffer 4mg IV/TID

4) Inj.Tramadol 50mg/day - 100mlNS

                                              Iv/TID

5) Strict I 10 CHARTING 

6) Inj. THIAMINE 10mg in 100ml NS/IV/OD

7) BP/PR/RR/SpO2 CHARTING

      GRBS 4th hrly

8)SYP.CREMAFFINE plus 15ml Po/ns

9) INT INSUGEN 

                    8am.         2pm.          8pm

   

    Npn          12u.           -                12u

    Reg.          8u.           8u.               8u