Unit 3 General Medicine case
Hellooo everyone... I am Dr.Srujana Reddy Kondamadugula , an intern posted in General Medicine department & one of the important terms of getting the internship completion is to complete my log book with my online log of what I learn during the course of my duties.
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.
Here is a which I have seen
A 55 yrs old female patient came from a village, in mid southern india came to casuality on 19/08/2020 with complaints of vomitings since 15 days & generalised weakness since 10 days
15 yrs back she went to local hospital with symptoms of excessive eating, increased urination, weaknesses & then diagonesd as denovo diabetes melitus type 2 ( underwent routine investigations :RBS as her grandson is a doctor and diagnosed as Diabetes Mellitus), she used oral hypoglycemic agents for 5 yrs & stopped 5 yrs as her suagr levels subsequently showed within normal levels but later she again went to hospital & was started on oral medications & was using continuously but stopped from last 16 days.( since 15 days she was started on insulin as her hba1c and sugars were high)
10 yrs back she went to local hospital with complaints of headache , neck pain, tingling sensation of arms & soles. Was diagnosed on denovo hypertension where her regular BP recordings were around 150/90 mm hg but never took any medications assuming that her bl was normal and she started using medications from last 1 yr only (TELMEKIND 40) .
3 yrs back she noticed a swelling with blebs over right foot, with Itching of same side leg till knee and associated with fever ; after a month few blebs resolved on antibiotics over foot but one of the blebs transformed into an ulcer & the ulcer is of size about 5* 4 cm with 1.5 cm depth.
2yrs back she went to local hospital with complaints of shortness of breath, & wheezing and cough then she was diagnosed with COPD & was started on inhalers which she stopped 2 months back.
From last 15 days she is complaining of
vomitings : 2- 3 times per day , contents food particals , non projectile, non bilious , no Hematemisis.
From last 10 days complaints of giddiness & generalised weakness
No h/o chest pain, Shortness of breath, palpitations, loose stools, pain abdomen, fever, weakness of limbs, focal neurological deficit.
Family history :
Her mother was a k/c/o hypertension, also her first degree relatives ( 2 sisters ) are k/c/o DM type 2 .
General examination :
On examination pt is conscious, coherent, cooperative, oriented to time, place & person, moderately built & nourished.
Vitals:
BP: 200/110mmhg ,
PR : 98 bpm,
RR : 17cpm,
Spo2 : 98%,
Temp: 98.4 °F,
GRBS : 293mg/dl .
No pallor, icterus , clubbing, cyanosis, koilonychia, lymphadenopathy & pedal edema .
Systemic Examination :
Respiratory system : bilateral air entry present, trachea central, normal vesicular breath sounds heard, no adventitious sounds heard.
CVS : S1, S2 heard, no murmurs
Per abdomen:
Shape of abdomen: scaphoid,
No tenderness and local rise of temperature,
No palpable masses.
Hernial orifices normal.
No free fluid and bruit.
Liver and spleen : not palpable.
Bowel sounds: normally heard.
CNS :
Higher Mental Functions: patient is concious, coherent, cooperative, oriented to time, place & person.
Speech is normal in pitch & tone .
Memory : recent & remote memory intact .
Cranial nerves : all cranial nerves intact.
Motor System :
Tone : UL LL
Rt N N
Lt N N
Bulk :
Rt N N
Lt N N
Power :
Rt N N
Lt N N
Hand grip: 100% 100%
Sensory system :
Rt Lt
Fine touch N N
Crude touch N N
Pain/temp N N
Vibration N N
Joint position N N
Proprioception N N
Reflexes :
Superficial reflexes :
Rt Lf
Corneal Present present
Conjunctival present present
Abdominal present present
Plantar --- ---
Deep tendon reflexes :
Rt Lt
Biceps --- ---
Triceps --- ---
Supinator --- ---
Knee --- ---
Ankle --- ---
Cerebellum : No finger nose incoordination
Kneel heel test : normal
No signs of meningeal irritation
GCS : 15/15
Provisional diagnosis : Diabetic Keto Acidosis with uncontrollable sugars.
Investigations :
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ABG :
pH: 7.40,
pco2 : 30.2 mm hg,
pO2: 94.5 mmhg,
HCO3 : 18.6 mmol/ L
CUE : albumin: ++, sugars : +++, pus cells : 4-6
LFT :
Total billirubin : 1.6 mg/dl,
Direct bilirubin : 0.3 mg/ dl ,
ALP : 210 ,
Total protein: 5.5 gm/ dl,
Albumin : 2.9 gm/dl
RBS : 390mg/ dl
CBP :
Hb: 11.8 gm/dl,
TLC : 9,500 cells / mm3,
Neutrophils : 85%,
Lymphocytes : 10 % ,
PCV : 35.6 vol% ,
MCV : 69.1 Fl,
MCH : 229 pg ,
RBC count : 5.15 millions / mm3,
Smear : normocytic normochromic blood picture with neutrophilia
Urine ketone bodies : initially positive but when repeated after 6 hrs it turned out to be negative.
X ray right foot : ap & lateral view
Chest X-ray PA view
Treatment:
Pt attenders were counselled adequately about her condition and course of disease in their own language and the difficulty in managing .
IV Fluids
0.9% NS with 1 ampule KCL ( 20mEq) &
RL at 100 ml/hr
Tab. TELMA -H ( 40 / 12.5) OD
Inj. HAI s/c after informing GRBS
14 U s/c stat
Inj. PAN 40 mg / iv/ OD
Inj. ZOFER 4mg / iv/ TID
Monitor BP, PR, RR, GRBS monitoring hourly
Inj. HAI 40 units (1ml) in 39 ml of 0.9%NS IV infusion @ 4 ml / hr & taper insulin accordingly.
Inj. AUGMENTIN 1.2gm/ IV / BD
𝘿𝙖𝙮 2
S - patient complaints of nausea,, pain in right loin region.
O- pt C/c/o ,, BP- 190/100mmhg, PR :90bpm, Temp- afebrile, grbs@8am- 266mg/dl. URINE for ketone bodies - negative., ABG - PH - 7.34, PCO2- 31.9. HCO3- 16.8. SERUM CREATININE- 1.7MG/DL, BLOOD UREA - 30Mg/DL. Na- 133, k- 3meq/l, cl- 96.
A- DKA RESOLVING, AKI , DIABETIC FOOT.
P- DRESSING DONE,
INJ .HAI 16 UnitsS/C, IV ANTIBIOTICS, IV FLUIDS, INJ KCL 2 ampules in 500ml NS Tab Nicardia10mg.
Investigations:
Serum electrolytes
Sodium : 127 mEq/L
Potassium : 3.2 mEq/L
Chloride : 90 mEq/L
Urine for ketone bodies : negative
ABG
pH: - 7.34,
pCO2- 31.9 mmhg
HCO3- 16.8mmol/L
ECG :
2D ECHO
USG - Abdomen with pelvis
Treatment :
Inj. HAI s/c 16 units @ 8am & inform GRBS at 2 pm & 8 pm
Inj. AUGMENTIN 1.2 gm /iv/ BD
IV fluids 3 NS & 1 RL @ 100ml/hr
Tab. NICARDIA 10 mg OD
Inj. KCL 2 ampules in 500 ml NS Iv over 5 hrs
Inj. ZOFER 4 mg /iv/TID
Inj. PAN 40 mg/iv/OD
Tab. LIMCEE 500mg OD
Tab. MVT OD
BP monitoring hourly & GRBS 4th hourly
GRBS charting:
CBP after 4 hrs
Hb : 9.3gm/dl
PCV : 28.1vol%
MCV : 70.1fl
MCH : 23.2pg
Serum potassium : 3.6 mmol/L
Serum creatinine : 1.4mg/dl
Treatment :
Inj. AUGMENTIN 1.2 gm/iv/ OD
Inj. PAN 40 mg /iv/ OD
IV fluids 2 NS, 1 RL continuous infusion @ 100ml / hr
Inj. PERINORM 10mg/iv/BD
Inj. HAI s/c after informing GRBS
14U --- 14U --- 14U
Tab. AMLONG 10 mg BD
Tab. LIMCEE 500mg OD
Tab. MVT OD
Syp. CREMAFFIN plus 15 ml BD
Tab. PCM 650 mg TID
Inj. NEMOL 1gm infusion if( temp >101°F)
Tab. NICARDIA 10 mg TID
Monitor BP, PR, RR 2nd hourly, GRBS charting 4th hourly
Foot end elevation with active right toe & leg movements
Fever Chart :
Inj. AUGMENTIN 1.2 gm/iv/ OD
Inj. PAN 40 mg /iv/ OD
IV fluids 2 NS, 1 RL continuous infusion @ 100ml / hr
Inj. PERINORM 10mg/iv/BD
Tab. AMLONG 10 mg BD
Tab. LIMCEE 500mg OD
Tab. MVT OD
Syp. CREMAFFIN plus 15 ml BD
Tab. PCM 650 mg TID
Inj. NEMOL 1gm infusion if( temp >101°F)
Tab. NICARDIA 10 mg TID
Tab. OROFER -XT OD
CLINGEN vaginal pessary PV /OD
Monitor BP, PR, RR 2nd hourly, GRBS charting 4th hourly
Foot end elevation with active right toe & leg movements .
BP Charting :
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