Skip to main content

48 year old with hyperglycaemia

 GM e log

Nov,03 2023
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.
IMMANI AASRITHA

Roll no.49

8th semester

Nov 01, 2023

GENERAL MEDICINE

48 year old male Patient lorry driver by occupation came to general medicine department with c/o 
Dragging type of pain in both upper and lower limbs since 1 week
Generalized weakness since 4 days
Fever since 1 day


HOPI
patient was apparently asymptomatic 1week back then had dragging type of pain in upper and lower limbs since 1 week which is continuous,aggravated on working with no relieving factors associated with generalized weakness
C/o fever since 1 day intermittent in onset,high grade,not associated with chills and rigors,more during night,no aggravating factors and relieved on medication.
No c/o cough,cold,sore throat
No c/o headache
No c/o burning micturition 

Past History
K/c/o DM type II since 5 years 
N/K/c/o hypertension,CAD,TB,asthma,epilepsy 
No similar complaints in the past

Personal History
Mixed diet
Normal Appetite
Regular bowel and bladder movements
Sleep - adequate
Addictions
H/o Alcohol intake for 20 years,stopped 5years back
H/o smoking beedis for 20 years,stopped 5 years back

Treatment History 
Drug History
Tab.voglibose 0.2mg 
Tab.Gliclazide 40mg 
Tab.Metformin 500mg PO/OD for diabetes since 5 years

Family History
No significant family history

GENERAL EXAMINATION
patient is conscious,coherent and cooperative 
Moderately built and malnourished 
Pallor present


No signs of icterus,cyanosis,clubbing,edema of feet and lymphadenopathy 

VITALS
temperature - 100.8F
Pulse rate - 80bpm
BP - 100/ 60 mmHg
RR  - 18 cpm
GRBS - 393 mg/dl

SYSTEMIC EXAMINATION 
CARDIOVASCULAR SYSTEM 
S1,S2 heard,no murmurs,no thrills

RESPIRATORY SYSTEM 
position of trachea - central
Normal vesicular breath  sounds 
No dyspnea and wheeze

PER ABDOMEN
Shape of abdomen - scaphoid

Umbilicus is central in position
No Tenderness on Palpation
Temperature - High
Liver is non palpable 
Spleen is non palpable 
Bowel sounds heard

CNS - NFND


INVESTIGATIONS 
2d echo


ECG
Fever chart s
vitals

25/10/23
RBS - 461mg/dl
Blood urea - 32mg/dl
Albumin - nil
Pus cells - 2-3
Epithelial cells - 1-2
Serum creatinine - 0.9
Na - 136mEq/L
K - 3.9 mEq/L
Cl - 101mEq/L
Ca- 1.04mg/dl
Hb - 14.1gm/dl
TLC - 4300 cells/cumm
PCV - 38 vol%
platelets- 1.50lakhs/cumm
HbA1C - 7.5

26/10/23
Na - 135mEq/L
K - 3.5 mEq/L
Cl- 99mEq/L
Ca - 1.10 mg/dl
Hb - 12.2gm/dl
TLC - 11300 cells/cumm
PCV - 32.5 vol%
Platelets - 2.70 lakhs/cumm

27/10/2023
Hb - 12.3gm/dl
TLC - 6400cells/cumm
platelets - 2.08 lakhs/cumm
Na - 130mEq/L
K - 4.4 mEq/L
Cl - 96 mEq/L
Ca - 1.09mg/dl

ABG analysis


pH - 7.32
pCO2 - 32.7mmHg
pO2 - 45.7 mmHg
HCO3 - 16.4mEq/L
PROVISIONAL DIAGNOSIS
DIABETIC KETOACIDOSIS with pyrexia under evaluation k/c/o DM II since 5 years

TREATMENT
25/10/23
Inj.Human actrapid insulin 6 units IV/ Stat 
          1ml insulin [HAI] 6units stat
IV fluids NS @ 100ml/hr
IV fluids 5% dextrose - to maintain dextrose
Tab.Dolo 650mg PO/TID
Monitor GRBS hourly
Monitor Vitals hourly

26/10/23
Inj Monocef 1gm IV/BD
Inj.Human actrapid insulin 6 units IV/ Stat 
          1ml insulin [HAI] + 39ml NS
Inj.Dextrose IV
IV fluids NS @ 100ml/hr
Monitor Vitals hourly
Inj.H actrapid
Inj.NPH insulin

27/10/23
Inj Monocef 1gm IV/BD
IV fluids NS @ 100ml/hr
Inj.Human actrapid insulin TID
Inj.NPH insulin sc SOS acc to GRBS
Inj.Pan 40mg IV/OD/BBF
Inj Neomol 1 gm IV/SOS if temp is 101F
Monitor GRBS
Monitor vitals. 



Comments

Post a Comment

Popular posts from this blog

gm case

GM e log July 08, 2022 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. IMMANI AASRITHA Roll no.49 5th semester July 10, 2022 GENERAL MEDICINE. CASE REPORT: A 49year old female patient resident of west bengal and farmer by occupation came to the OPD with chief complaints of pain in multiple joints and headache. HISTORY OF PRESENT ILLNESS: The patient was apparently asymptomatic 10 years back. C/o pain in shoulder joint, ankle joint, mcp and mtp joints,pip joint, wrist, elbow and knee joints since 10 years. (More in the ...
Post a Comment
Read more

49 Aasritha, GM, 52 year male with LL(R) swelling

IMMANI AASRITHA 3rd sem, roll num:49 under the guidance of Dr. Rishik (Intern) This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission. 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 a diagnosis and treatment plan. CASE SCENARIO: A 52yr old patient came to the ward on 29 June 2021 with chief complaints of right lower limb swelling, intermittent fever (alive and well), shortness of breath since 3days, and burning micturition for 15 days. HISTORY OF PRESENTING ILLNESS The patient was asymptomatic 5days ago, after which he developed right lower limb swelling up to the knee. No H/O trauma, thorn prick, nausea, vomiting c/o a small wound, watery discharge since 2 days Fever- 5days intermittent, low grade, a/w chill A light rise in temp so...
Post a Comment
Read more

A 60F with megaloblastic anemia

  Nov29, 2023 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. IMMANI AASRITHA Roll no.49 8th semester Nov 28, 2023 GENERAL MEDICINE DOA - 27/11/2023 CHIEF COMPLAINTS : Fever since 1 week Palpitations since 1 week  Generalised weakness since 4 days  Blood in stools since 3 days  Chest pain and tightness since 4 days HISTORY OF PRESENTING ILLNESS  The patient was apparently asymptomatic 1 week ago and then she developed fever which is sudden in onset, high grade, associated with chills and rigors, relieved tempor...
Post a Comment
Read more