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
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:
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
posted by 54 Harika Kathumandi @ June 22, 2023
<< Home