Unit 3 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 20/08/20 with cheif complaints of vomiting since yesterday and pain  abdomen since yesterday.

1yr back she went to local hospital with complaints of Generalised weakness and myalgia for three days & was diagnosed with denovo Diabetes Mellitus type 2 and took unknown medication. 

2 months back she developed similar complaints and went to local hospital (Diabetologist) where she was prescribed with :

 long acting insulin of 15 units daily once in the morning

Glimipride(2mg) + pioglitazone(15mg) + metformin (500mg) in morning

Sitagliptin(64.25mg) + metformin (500mg) in evening. 

2 days back she she developed fever which is sudden in onset and high grade, intermittent type & then she stopped insulin and continued oral hypoglycemic agents. 

Following which she developed vomitings of two episodes yesterday night at 10.30pm food particals as contents, Non bilious, Non projectile, No Hemetemisis. 

She had sudden onset shortness of breath since 10:30pm last night grade 4 . 

No H/O cheast pain, palpitations, Giddiness, dizziness, weakness of limbs no h/o loose stools 

General examination : 

On examination Patient was in altered state and irriatable but oriented to time place and person and obeying commands.

Vitals : 

BP : 110/100 mmhg

Pulse: 94bpm

Saturation: 99%

Temperature: Afebrile

GRBS: 527mg/dl 

RR : 30 cpm

No pallor, icterus ,  clubbing, cyanosis, koilonychia, lymphadenopathy & pedal edema . 

Systemic Examination :

CVS : S1 & S2 heard, No murmurs. 

Respiratory system : bilateral air entry present,  trachea central, Inspiratory crepitations heard in Both Right and left Infra Axillary area, Infra scapular area.

Per abdomen: 

Shape of abdomen: obese. 

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 KETOACIDOSIS with 

? URINARY TRACT INFECTION. 

? Pneumonia

Investigations : 

   𝘿𝙖𝙮 1

CBP-

 Hb 13.0gm/dl

TLC : 19,400 

GRBS - 527mg/dl

LFT - 

Total billirubin - 5.01

Direct bilirubin - 0.44

Alkaline Phosphatase- 146

Urine for ketone bodies : positive

CUE : 

Albumin ++

Sugars ++++

Pus cells 5-6

ABG 

pH - 7.0

pCO2 - 6.4mmhg

pO2 - 93.3

Hco3- : 1.5mmol/L

St. Hco3- : 4.9

ABG after 3 hrs 

ABG after 6 hrs 

RFT

Urea - 65

Uricacid - 9.4

Creatinine - 1.1

Ca2+ : 10.2

Po4 : 5.6

Na+ : 134

K+ : 3.8

Cl- : 98.

USG abdomen

IVC diameter : 5mm max

                           2mm max

B/L Grade 1 RPD changes. 

Cheast x ray 

Showing diffuse infiltrates in left lung. 

Blood culture : no growth of organisms 

FBS : 202mg/dl 

HBA1C : 7.0 %

Serum potassium : 4.2 mmol/L

Treatment : 

Treatment: 

Inj HAI 6 units iv stat

INJ. HAI 1ml in 39ml of 0.9% NS @4ml/hr and taper according to sliding scale. 

INJ. PAN 40mg IV OD

INJ. ZOFER 4mg IV TID

IV Fluids 0.9% NS infusion @20ml/kg followed by continuous infusion of 200ml/hr

IV Fluids 0.9% NS with 1 ampule KCL(20mEq) @100ml/hr

Inj Ceftriaxone 1gm iv BD 

GRBS monitoring hourly.

Bp , PR, RR monitoring hourly.

GRBS charting : 

𝘿𝙖𝙮 2 

S - two spikes of fever at 9.00pm (101.8F, PR = 106) & 8.00AM (101.2F, PR = 101) No other complaints

O - Bp = 110/70

      PR=94

      TEMP = 101.5F

      RR = 20

     sPo2 = 99

    GRBS = 248@9.00AM

 

CVS- S1, S2 Heard

RS - Bilateral air entry +

        Crepts in left infra axillary and infra scapular area

P/A - Soft, nontender

CNS - No focal deficits

pH - 7.34

Hco3- 11.7

Pco2 - 11.8

Spo2 - 95

Sr. K+ 4.1

Sr. Creatinine- 1.1

A - source of infection-? UTI

    Cause of fever - ? Pneumonia

 P - insulin infusion @3ml/hr

Inj. NEOMOL to decrease temp

TEPID sponging

Tab Azithromycin 500 mg od

Investigations : 

ABG : 

ABG after 3 hrs

Urine for ketones : positive 

Serum potassium : 4.1mmol/L 



CBP : 

Chest X ray : bedside ap view

Treatment : 

IV fluids NS, RL infusion @ Urine output + 30ml /hr . 

Inj. HAI 40 units (1ml ) in 39 ml NS infusion @2ml/hr

Inj. CEFTRIAXONE 1gm/iv/BD

Inj. METROGYL 100ml/iv/TID 

Tab. AZITHROMYCIN 500mg OD 

Nebulization with DOULIN & BUDECORT 6th hourly . 

Inj. PAN 40mg/iv/ OD 

GRBS monitoring hourly 

BP, PR, RR, & Temp 4th hourly. 

 Temperature Chart : 

𝘿𝙖𝙮 3 

Investigations : 

ABG : 

Serum potassium : 3.2mmol/L

Treatment : 

IV fluids NS, RL infusion @ Urine output + 30ml /hr . 

Inj. CEFTRIAXONE 1gm/iv/BD

Inj. METROGYL 100ml/iv/TID 

Tab. AZITHROMYCIN 500mg OD 

Nebulization with DOULIN & BUDECORT 6th hourly . 

Inj. PAN 40mg/iv/ OD 

Inj. s/c  HAI  8U --- 8U --- 8U 

      s/c  NPH 10 U -------- 10U 

GRBS monitoring hourly 

BP, PR, RR,  2nd  hourly & Temp 4th hourly.