MEDICINE CASE DISCUSSION
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I have been given this case, in an attempt to solve and understand the topic of "Patient's clinical data analysis”. This has helped me develop my competency in reading and comprehending clinical data including history taking, clinical findings and investigations. The goal is to come up with a diagnosis and treatment plan.
50 year old female patient presented with DKA with Acute gastroenteritis.
CHIEF COMPLAINTS:
A 50year old female patient presented to casuality with complaints of pain abdomen since 2 days and regurgitation of food since2 days.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 15 years back then she had a episode of giddiness, and was taken to hospital and diagnosed with Hypertension and is on regular medication MET-XL25 mg .
Untill 6 years back she was doing well and developed Bilateral knee joint pain for which she was advised to take analgesics .
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:
Paitent is having loss of appetite, Bowel 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:
picture showing pale palpebral conjunctiva
FEVER AND GRBS CHARTING :
Bp-130/80 mm Hg
Pr-97 bpm
Rr-25 cpm
Temperature:Afebrile
Spo2: 98%@RA
GRBS-411MG/DL
SYSTEMIC EXAMINATION:
P/A:
Inspection:
Abdomen is distended
Infraumblical vertical scar present
No sinuses,,pulsations, peristalsis.
Umblicus is central and inverted
All quadrants of Abdomen move equally with respiration.
Palpation:
No local rise of temperature
Tenderness present in the Right ,Left Hypochondrium and Epigastrium.
No fluid thrill
Liver is palpable
Spleen not palpable
Percussion:
Resonant note is heard on percussion
shifting dullness negative
Auscultation:
Bowel sounds are heard.
CVS:
S1,S2 heard No murmurs
CNS:
No focal neurological deficit
RS:
Bae+
Normal vesicular breath sounds heard.
INVESTIGATION:
URINE for Ketone bodies: Positive
Serum osmolaity:
Glycated Hemoglobin
Abg and serum electrolyte values
Liver function test
Blood Culture Report:
Chest X ray:
No sonological abnormalities detected
Provisional Diagnosis:
Diabetic ketoacidosis (resolved)
?Starvation ketoacidosis with Acute Gastroenteritis(resolved)
with Denovo DM2.
Treatment:
1.IVFluids NS @100ml/hr
2.Inj.HAI infusion 1ml(40U)in 39 ml NS@4ml/hr increase or decrease according to GRBS
3.IV 5Dextrose@50ml/hr increase or decrease according to GRBS
4.Strict I/O CHARTING
5.monitor Vitals Hourly
on 10/6/23
TREATMENT:
1-PLENTY OF ORAL FLUIDS
2-TAB GLIMI MI PO/BD
3-TAB PAN 40MG PO/OD/BBF
4-TAB ZOFER 4MG PO/BD
5-MONITOR VITALS HOURLY
6-GRBS 7 POINT PROFILE
INSULIN INFUSION ALGORITHM:
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