HarikaKathumandirollno54: June 2023

65/M C/O PAIN ABDOMEN,? ALCOHOLIC GASTRITIS

This is 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 patients 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 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.

CONSENT AND DE-IDENTIFICATION :

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.

CHIEF COMPLAINTS:

Patient came to the casuality with chief complaints of abdominal pain since 5 days.

HOPI:

Patient was apparently asymptomatic 5 days back then he developed pain in the abdomen more in the epigastric region , burning type , with no radiation ,Aggravated with food intake and relieved on taking medication.

Had similar complaints 1 year back - went to the hospital with abdominal pain and was diagnosed as jaundice for which he was treated.

DAILY ROUTINE:

He wakes up at 6 am and gets freshened up. Drinks tea at 7 am followed by breakfast ( rice with curry) at 9 am. Leaves home for work( works as Shepard) at 9am and works till 7 pm. In between eats lunch at 2 pm and drinks tea at 5 pm. Eats dinner at 8 pm and sleeps at 9 pm.

PAST HISTORY:

Not a k/c/o Dm, Htn, asthma, Epilepsy, thyroid disorders, cad, cvs

Had similar complaints 1 year back - went to the hospital with abdominal pain and was diagnosed as jaundice for which he was treated.

SURGICAL HISTORY:

Operated for B/l hydrocele and hernia 20 years back.

PERSONAL HISTORY:

Diet: Mixed

Appetite: decreased

Sleep: Adequate

Bowel and bladder movements: Regular

Addictions:

Alcohol consumption since 45 years every day and occasionally since 10 years.

Smoking since 40 years stopped 1 year back.

GENERAL EXAMINATION:

Patient is conscious,coherent,cooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.

Temp:97.8F

Bp:120/80 mm Hg

Rr:18 cpm

Pr:81 bpm

SYSTEMIC EXAMINATION:

PER ABDOMEN

Inspection:

- Abdomen is obese

- Umbilicus is central

- All quadrants move equally with respiration.

- No scars, sinuses, engorged veins

Palpation:

- soft

- Tenderness present over left hypochondrium, epigastric region.

- No local rise in temperature

- All the inspectory findings are confirmed

Percussion:

Resonant

Auscultation:

Bowel sounds heard.

CNS: nfnd

CVS: S1 S2 heard,No murmurs

RS: blae+ , NVBS heard

Investigations:

24/6/23

Hemogram:

Hb-11.9 g/dl

Tlc-6500

Pcv-35.1

RBC -4million/mm³

Platelet count-1.5 lakhs

Blood urea- 17 mg/dl

Liver function test:

Serum Electrolytes:

Blood urea-17 mg/dl

Serum Creatinine -1.0 mg/dl

Serum Amylase-29 Iu/L

SERUM LIPASE-10 Iu/L

Complete Urine Examination:

SEROLOGY-NEGATIVE

Random Blood sugar- 131 mg/dl

25/6/23

Fasting blood sugar- 104 mg/dl

Prothrombin time- 17 seconds

Aptt- 35 seconds

Inr-1.25

GLYCATED HEMOGLOBIN - 6.5

LDH- 249

Peripheral Smear-

Serum electrolytes-

26/6/23:

27/6/23:

Hemogram

Serum Electrolytes:

Liver function test:

28/6/23:

29/6/23:

DIAGNOSIS:

Pain abdomen secondary to ? Alcoholic gastritis? Acute pancreatitis

TREATMENT:

- Nbm till further orders

-Iv fluids: Ns, RL, DNS @ 100ml/hr

- inj. Thaimine 200mg iv/bd

- inj. Tramadol 1 amp in 100ml ns/iv/ sos

- inj. Pan 40 mg/iv/od

- inj zofer 4 mg iv/sos

- inj. Buscopan im/sos

47 Y/M Diabetic since 10 years,anemia under evaluation, Hypoglycemia .

This is 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 patients 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 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.

CONSENT AND DE-IDENTIFICATION :

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.

Pt c/o Unresponsiveness since 5 am on 18/6/ 23

HISTORY OF PRESENTING ILLNESS:

Pt was apparently asymptomatic 10 years ago went to hospital for routine checkup and was diagnosed with DM type 2 ,since then he was on tab.Glimi M1 500 mg Po/Od.

Patient complains of decreased appetite since 6 months .

Patient was alright 1 week ago,pt came to casualty with a Hypoglycemic episode ( Giddiness) managed conservatively and not willing for admission at that time.

Patient was alright for 1 week bought to casualty,his Grbs at presentation was 35 mg/dl.

After starting 25 D 100 mlIv/Stat,then Grbs was 168 mg/dl,pt became responsive.

C/o Burning micturition since 4 days .

No c/o fever,cold,cough, vomiting,loose stools

No c/o Sob,chestpain, palpitations,orthopnea,PND .

No c/o pedal edema, Facial puffiness, decreased urine output.

On 20/6/23 pt had fever spikes (103.F ) high grade , intermittent,not associated with chills and rigor.

C/o Vomitings 2 episodes food as content,non projectile,non bilious.

C/o loose stools 4 episodes

Past History:

Operated for cataract 20 years ago.

Personal History:

Appetite - decreased

Diet-mixed

Sleep- adequate

Bowel and bladder movement - Regular

Addictions- 5-6 cigarettes/day since 20 years

Occasional alcoholic since 20years. Ii

Daily routine:

He used to be a bus driver for 10 years

He started driving a lorry driver after his son death he stopped working as lorry driver .

Started driving an Auto for 2 years then he stopped working 6 months back .

General Examination:

Pt is conscious, coherent, cooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy,edema.

Vitals:

Temperature -afebrile at presentation

Fever spikes since 20/6/23

Bp-150/80 at presentation

Pr- 102 BPM

Rr-16cpm

Grbs-35 mg/dl

Spo2-98%@RA

Input /output charting:

18/6/23-

Input-1760 ml, Output -1100ml

20/6/23-

Input-1100 ml, Output -1200ml

Clinical images:

SYSTEMIC EXAMINATION:

CVS:Apex 5th ICS medial to mid clavicular line,

S1,S2 heard ,no murmur

RS:Tracheal central

Chest elliptical

bilaterally symmetrical

Chest movements normal

Normal vesicular breath sounds heard

P/A :Soft,Non tender

No organomegaly .

CNS:No focal neurological deficit.

Investigations:

Serology- Negative

Rbs- 90 mg/dl

Serum Uric acid-7.7 mg/dl

Serum creatinine - 1.9 mg/dl

Blood urea- 46 mg/dl

USG Abdomen:

20/6/23

Serum creatinine -2.0 mg/dl

Blood urea- 36 mg/dl

Fbs-157mg/dl

21/6

PROVISIONAL DIAGNOSIS:

Hypoglycemia secondary to oral hypoglycemic agents with ?Hospital Acquired Diarrhoea (Resolving)with Anemia with k/c/o DM-2 since 10 years with ?diabetic nephropathy

TREATMENT:

1.Iv fluids NS @ 75ml/hr strict I/o charting

2. stop oral hypoglycemic agents until further orders.

3. inj. Neomol 1gm/iv/sos ( if temp>= 101F)

4.inj. Zofer 4mg / iv/ sos

5. inj. metrogyl 500mg /iv/ tid

6. Tab sporolac 2 tabs po/tid

7. Tab. baclofen 10mg /po/bd

8.Tab dolo 650 mg PO/sos

9.ors solution 200ml after every stool

10.GRBS 7. Profile monitoring

11.Vitals monitoring 2nd Hourly

50/F with diabetic keto acidosis

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 patients 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 comment box is welcome .

A 50year old female patient who resides at presented to casualty with complaints of pain abdomen 2 days back, regurgitation of food .

Patient was apparently asymptomatic 15 years back then she had a episode of giddiness,was taken to hospital and diagnosed with Hypertension and on regular medication MET-XL25 mg.

Till 6 years back she is doing well developed Bilateral knee joint pain for which she was advised to take anlgesics .

She started to take antacid medication since 4 years

1 month back patient developed facial puffiness,pedal edema was taken to nearby hospital and was told she is having Fatty liver managed conservatively from then she used to develop pedal edema on &off .

Patient complaining of loss of appetite, regurgitation of food, difficulty in swallowing

5 days back

1 episode of vomiting bilious ,non projectile ,food as content

3 episodes of loose stools non sticky,foul smelling, yellow coloured, small quantity,not associated with blood

Abdominal pain squeezing type non radiating , continuous in nature,with no aggravating and relieving factors

Pt presented to casualty on 3/6/23 evening

On checking her GRBS it was found to be HIGH.

URINE for ketone bodies found to be positive.

Past History:

Not a k/c/o Tb, epilepsy,cad,CVD,Asthma, thyroid disorders.

Family History

Not significant

Personal History:

Pt is having loss of appetite, vowel movements increased ,micturition- 7-8 times /day ,sleep - inadequate,No addictions.

Daily routine:

Patient used to be a maid 6 years back and stopped working due to bilateral knee joint pain and used to stay at home

Patient wakes up at 6:30 am ,does her daily activities and drinks Java at around 7:30 , breakfast by 8 am ,watches Tv will have her lunch by 2 pm ,takes Tea by 6 pm and dinner by 9 pm and sleeps by 10 pm.

General Examination:

Pt is conscious, coherent,cooperative

Pallor present

no icterus,cyanosis, clubbing,generalised lymphadenopathy,edema.

Clinical images: