68YR OLD MALE. WITH VOMITINGS

This is online E log book to discuss out patients de-identified health data shared after taking his / her guardian`s 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 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 comments box is welcome .

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.
Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references

Patient came with c/o
            vomitings since 1day
             Belchings since 1day
HOPI
Patient was apparently assymptomatic 1day ago then she developed vomitings since 1day watery ,content -food particles?bilious(greenish black) ,non projectile,blood stained ,Non projectile,not blood stained,non foul smelling 
N/H/O abdominal pain ,loose stools,giddiness
Belching+
Patient irritable in the night,didn't sleep properly 
N/H/O fever,cough

Past history-k/c/o type 1DM since 15yrs 
on biphasic insulin
(10U -----x------15U)
N/k/c/o  HTN,Epilepsy,Tuberculosis,Leprosy, asthma

Personal history-
Diet-mixed
Sleep-adequate
Appetite-normal
Bowel and bladder-regular
Addictions -none
Allergies-none

Family history -
Not significant 

 General examination 
Patient was conscious, coherent, cooperative and well oriented to time and place. 
Moderate built and moderate nourished 
No pallor, Icterus, Cyanosis, clubbing, pedal edema, Lymphadenopathy.

Vitals:

BP: 140/60mmhg
PR: 102bpm
RR: 20 cpm
GRBS: 335 mg/dl
SPO2: 98% at RA


Systemic examination
CVS:S1 S2+. No murmurs
RS:BAE+
CNS: 
GCS -E4 V5 M6
Power- UL.     5/5.       5/5
                LL.      5/5.      5/5
Tone-    UL.        N.          N
                LL.        N.          N
Reflexes:
             B. 2+.    2+
             T. 2+.    2+
             S 2+.     1+
             K. 2+   . 2+
             A. 1+.    1+
       Plantar flexion. flexion 
P/A. Soft,non tender
INVESTIGATIONS
RANDOM BLOOD SUGAR :343 mg/dl 
HbA1c-7%
Urine for ketone bodies -positive

RFT-

LFT
Hemogram
Ecg
USG ABDOMEN

2D ECHO-
ABG-
Diagnosis-
Vomitings under evaluation with diabetic ketosis with type 2 DM

TREATMENT-
1) PERINORM. 10mg  IV/stat

2) IV fluids RL @75ml/hr

3)Tab.NICARDIA 20mg po/stat

4)monitor vitals & inform sos

5)Inj. HAI 40 IU in 39 ml NS @4ml/hr to maintain grbs between 150 to 250mg/dl

6)PROMETHAZINE 25mg IV/stat

7)TRANEXA 500 mg IV/stat.


Day 2(25/08/23):

S-
Nausea subsided
No Vomitings 
Hiccups reduced

O:  Patient is conscious/coherent/cooperative 
Afebrile on touch
Bp: 160/100 mmhg
PR: 88bpm.
RR: 18 cpm
SPO2: 98% at RA
GRBS: 269 mg/dl 
INPUT -  1040ml
OUTPUT-500ml
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: 
GCS -E4 V5 M6
Power- UL.     5/5.       5/5
                LL.      5/5.      5/5
Tone-    UL.        N.          N
                LL.        N.          N
Reflexes:
             B.    2+.     2+
             T.     1+.       1+
             S       1+.      1+
             K.      2+.      2+
             A.      1+.      1+ 
 Plantar.      Flexion.  Flexion
P/A: Soft, no organomegaly, bowel sounds heard 
Investigations 

 
A: diabetic ketosis with AKI (?Drug induced) with type 2 DM

P:  
1.INJ.HAI 40IU in 39ml NS @2ml/hr to maintain GRBS between 150 to 250mg/dl

2.IV fluids NS@75ml/hr

3.Inj.5D @30ml/kg(if grbs<150mg/dl)

4.Inj.PAN 40mg IV/BD

5.Inj.zofer 4mg IV/Tid

6.Inj.PROMETHAZINE  IV/

7.TAB.NICARDIA 10mg/sos

6.syp.CITRALKA 10ml in glass of water
 po/tid

7.Tab.NICARDIA

7.strict I/O charting

8.monitor vitals and inform 

Day 3 (26/08/23)
S: 
Patient feels better today, 
Nausea subsided
No complaints of vomitings .
Hiccups reduced
                                            
O:  Patient is conscious/coherent/cooperative 
Afebrile on touch
Bp: 110/60 mmhg
PR: 88bpm.
RR: 18 cpm
SPO2: 98% at RA
GRBS: 159 mg/dl (10U HAI given) 
INPUT -  1140ml
OUTPUT-900ml
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: 
GCS -E4 V5 M6
Power- UL.     5/5.       5/5
                LL.      5/5.      5/5
Tone-    UL.        N.          N
                LL.        N.          N
Reflexes:
             B.    2+.     2+
             T.     1+.       1+
             S       1+.      1+
             K.      2+.      2+
             A.      1+.      1+ 
 Plantar.      Flexion.  Flexion
P/A: Soft, no organomegaly, bowel sounds heard 
Investigations :
Hemogram
RFT

T3,T4,TSH

PLBS

URINE FOR KETONE BODIES
A: diabetic ketosis with AKI (?Drug induced) with type 2 DM

P:  
1.INJ.HAI 40IU in 39ml NS @2ml/hr to maintain GRBS between 150 to 250mg/dl

2.IV fluids NS@75ml/hr

3.Inj.5D @30ml/kg(if grbs<150mg/dl)

4.Inj.PAN 40mg IV/BD

5.Inj.zofer 4mg IV/Tid

6.syp.CITRALKA 10ml in glass of water po/tid

7.strict I/O charting

8.monitor vitals and inform sos

9.INJ.PROMETHAZINE 25mg IV/BD

10.Tab.AMLONG 5mg PO OD

Day4 (27/08/23)
27/08/23   

 S-
  No Vomitings 
  Hiccups reduced
  Episodes of hypoglycemia at midnight 
  Stools not passed

O-
Patient is conscious,coherent,cooperative 
afebrile on touch
 PR.- 92/min
RR.- 18/min
Bp-130/70mm hg
GRBS-159mg/dl(10U HAI 8 NPH)
INPUT-2250ml
OUTPUT-950ml
Cvs-S1S2 +,no murmurs heard
RS-Bilateral air entry+,NVBS heard
CNS-
GCS -E4 V5 M6
Power- UL. 5/5. 5/5
                LL. 5/5. 5/5
Tone- UL. N. N
                LL. N. N
Reflexes:
             B. 2+. 2+
             T. 1+. 1+
             S 1+. 1+
             K. 2+. 2+
             A. 1+. 1+ 
 Plantar. Flexion. Flexion
P/A: Soft, no organomegaly, bowel sounds heard 

Investigations:



A-DIABETIC KETOSIS (RESOLVED)with AKI (? DRUG INDUCED - RESOLVING with TYPE 2 DM ? Denovo HTN

P-
1)plenty of oral fluid

2)inj.HAI S/C TID

3)strict I/O charting

4)monitor vitals and inform sos



Popular posts from this blog

46 YEAR OLD MALE WITH FEVER,ABDOMINAL DISTENSION AND DARK COLORED STOOLS

Image
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. A 46 year old male patient presenting with c/o : • Fever since 6 days. • Dark coloured stools since 6 days • Yellowish discolouration of sclera and urine. • Abdominal distention since 3 days  History of presenting illness :          Patient was apparently asymptomatic 6 days back following  which     He developed Fever which was associated with chills and cold and aggravated at night.      3 days after fever started the patient developed abdominal distention which was insidious in onset and not progressing.    5 days following fever the patie...
Read more

INTERNSHIP ASSESSMENT

T.AKSHITHA REDDY ROLL NO - 16 2017 BATCH Here, I have explained all the things that I've learnt and did in my General Medicine internship postings during 2023. Period of posting : 04-07-23 to 01-09-23 Cases- 1)   https://186akshithareddy.blogspot.com/2023/08/68yr-old-male-with-vomitings.html 2) https://186akshithareddy.blogspot.com/2023/08/this-is-online-e-log-book-to-discuss.html 3) https://186akshithareddy.blogspot.com/2023/08/60yr-old-male-with-headache-and-altered.html 4) https://186akshithareddy.blogspot.com/2023/07/41yr-old-female-with-vomitings-and.html 5) https://186akshithareddy.blogspot.com/2023/12/is-online-e-log-book-to-discuss-out.html PSYCHIATRY DUTIES ( 04-07-2023 to18-07-2023) Learnt history taking in psychiatry cases.  Have seen cases of-  -Psychosis in alcohol withdrawal -Alcohol dependence syndrome   -panic attacks  -Depression We also got a chance to observe cases in the de-Addiction centre, and counsel the patients undergoing therapy....
Read more

80 YEAR OLD MALE WITH SOB AND COUGH

Image
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.   80 YEAR OLD MALE resident of pochampally came with c/o      . Shortness of breath since 4 days      . Cough since 4 days HOPI          Patient was apparently asymptomatic 4 years back then he developed chest pain which radiated to the left arm for which he went to the hospital and after investigations diagnosed with  anterior wall myocardial infraction and right bundle branch block on ecg for which he underwent percutaneous transluminal coronary angioplasty in 2017.        And is on medications T.ecospirin AV   (70/...
Read more