45 year old female with pain abdomen since morning, vomiting since 6 hours, constipation since 2 days.

 

This is an a 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.

VISHAL SARDA

ROLL NO:-93

UNIT-I

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the 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 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 

CASE PRESENTATION:-

Patient came to the casualty with complaints of pain abdomen since morning, vomiting since 6 hours , constipation since 2 days.

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently alright since morning after which she developed pain abdomen which was sudden in onset, gradually progressive , twisting type, non-radiating, aggravated on taking food and relieved on taking medication.patient complaints of 3 episodes of vomiting , non - projectile , containing food particles and watery in consistency .c/o constipation since 2 days.

No h/o chest pain, fever, palpitation, sweating, headache, cough, cold, burning micturition, diarrhoea.Patient tells that she fought with her husband and was emotionally stressed.

PAST HISTORY:- 

K/c/o type -II diabetes since 5 years and is on Tab.Glimiperide -m1 1 mg  po bd.

K/c/o hypothyroidism since 5 years and is on Tab. Levothyrox 25 mcg.

TREATMENT HISTORY:- 

K/c/o. Diabetes since 5 years , on tab .glimiperide m1- 1mg po bd.

History of surgery- right great toe amputation 5 years back.

PERSONAL HISTORY:-

Diet - mixed

Appetite- normal

Bowel and bladder- constipated

Sleep- adequate

Addictions- none.

MENSTRUAL HISTORY:-

Age of menarche- 13 years.

Regular cycles -28/4, LMP- 3/12/2023

GENERAL EXAMINATION:-

Patient is conscious, coherent, cooperative, moderately built and nourished.

Pallor present.

No icterus, cyanosis, clubbing, lympadenopathy, edema.

VITALS:-

Temperature - 97.4 F

BP- 160/90 mmhg

PR- 104 bpm

RR- 16 cpm

GRBS- 448 mg/dl.

SYSTEMIC EXAMINATION:-

CVS- S1, S2 heard, no murmurs

RS- b/l AE +, NVBS heard.

P/A- soft , non tender ,no organomegaly, bowel sounds present.

CNS- NFND

INVESTIGATIONS:-                on 12/12/2023:-

Urine for ketone bodies:-

GRBS monitoring:-

Hemogram-

Chest x - ray:-

USG ABDOMEN-

ECG-

FEVER CHARTING-

SEROLOGY-

BLOOD GROUPING -

CUE-

PERIPHERAL SMEAR:-

RETICULOCYTE COUNT-

FBS-

RBS-

BLOOD UREA-

LFT-

SERUM CREATININE -

SERUM IRON-

HBA1C-

SERUM ELECTROLYTES -

2D- ECHO-

On 13/12/2023:-

HEMOGRAM-

SERUM ELECTROLYTES -

PROVISIONAL DIAGNOSIS:- Diabetic ketosis secondary to non-compliance to drug with hypothyroidism with microcytic hypochromic anaemia.

Treatment:-

INJ.HUMAN ACTRAPID INSULIN SC TID

INJ.NPH SC BD

IVFLUIDS @100 ML/HR

INJ.ZOFER 4 MG IV SOS

YAB.LEVOTHYROXINE 25 mcg

IINJ.PAN 40 MG IV OD

SYRUP.LACTULOSE 15ML BD

TAB.DOLO 650 MG PO TID