GENERAL MEDICINE CASE DISCUSSION
68 years old lady with lower abdomen pain & Type II Diabetes
May 14, 2023
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Cheif complaints :
68years old lady who is a resident of nalgonda came with
C/o loose stools 3-4 episodes per day since 1week
C/o pain abdomen since 4days
C/o fever with chills since 4days
C/o vomitings since 3days
C/o abdominal distension since 3days
C/o constipation since 2days
History of presenting illness :
Patient was apparently asymptomatic 1week back then she had c/o loose stools 3-4 episodes per day which lasted for 2days, watery, not a/w blood &mucus ,black coloured ,large volume followed by she had c/o pain abdomen in epigastrc region f/b diffuse colicky type(squeezing) & she also had c/o fever a/w chills which was high grde,intermittent, no evening rise of temperature, a/w vomitings, non bilious, non projectile ,food as content &abdominal distension. She also has c/o constipation since 2days.
Past History :
No history of similar complaints in the past.
K/c/o DM since 10 years on regular medication.
N/k/c/o HTN, Asthma, TB,CVD, CAD, Epilepsy
No past surgical history
No h/o blood transfusions.
Personal History :
Diet -Mixed
Appetite -Normal
Bowel & Bladder -Regular
Sleep -Adequate
No addictions & allergies
Family History :
Not significant
General Examination :
Patient is conscious,coherent, co-operative
thin built &moderately nourished
Pallor-present
Icterus-Absent
Cynosis-Absent
Clubbing-Absent
Lymphadenopathy -Absent
Pedal Edema -Present
Vitals @admission
Temp - 98.8F
PR- 116BPM
RR-22CPM
Bp-130/70mmHg
Spo2- 97%
GRBS-221mg/dl.
Systemic Examination
I) Per Abdomen :
INSPECTION :-
Shape of abdomen -Distended
Umbilicus - inverted
No scars, sinuses, straie
No visible pulsations & visible peristalsis
Movements of all 4 quadrants moving equally with respiration
PALPATION :-
All inspectory findings are confirmed
No local rise of temperature
Tenderness present in the epigastric region
No palpable mass present
No palpable lymphadenopathy
No organomegaly
Hernial orificies - Free
PERCUSSION :-
No signs of fluid thrill & shifting dullness
Resonant note heard (except liver dullness)
AUSCULTATION :-
Bowel sounds present
No bruit heard
II) Respiratory system :
Normal vesicular breath sounds heard
Bilateral air entry present
No added sounds
III) CVS:-
S1S2 heard ,No murmurs
IV) CNS :-
NAD, HMF intact
Investigations :-
15/5/23
Chest x-ray 16/5/23
X-ray Erect Abdomen
ECG
2decho
Provisional Diagnosis :
Pyrexia with thrombocytopenia with pain abdomen under evaluation with AKI secondary to sepsis with Type 2 DM since 10years.
Treatment :
14/5/23
Inj.PAN 40mg IV/OD
Inj. NEOMAL 1gm IV/SOS(if temp>101F)
Inj. ZOFER 4mg IV/SOS
Inj. HAI SC/TID a/c RBS
15/5/23
Inj.PAN 40mg IV/OD
Inj.MONOCEF 1gm IV/BD
Inj. NEOMAL 1gm IV/SOS(if temp>101F)
Inj. ZOFER 4mg IV/BD
Inj. BUSCOPAN IM/SOS
Inj.LASIX 20mg IV/STAT
Inj.FLACIGO 120mg IV(0-12-24-48)
Inj. HAI SC/TID a/c RBS
16/5/23
Inj.PAN 40mg IV/OD
Inj.MONOCEF 1gm IV/BD
Inj. ZOFER 4mg IV/BD
Inj. BUSCOPAN IM/SOS
Inj.LASIX 20mg IV/STAT
ZYTEE GEL for L/A TID
Inj. HAI SC/TID a/c RBS
Tab.DOLO 650mg PO/TID
17/5/23
Inj.PAN 40mg IV/OD
Inj.MONOCEF 1gm IV/BD
Inj. ZOFER 4mg IV/BD
Inj. BUSCOPAN IM/SOS
Inj.LASIX 20mg IV/OD
ZYTEE GEL for L/A TID
Inj. HAI SC/TID a/c RBS
Tab.DOLO 650mg PO/TID
18/5/23
Inj.PAN 40mg IV/OD
Inj.MONOCEF 1gm IV/BD
Inj. ZOFER 4mg IV/BD
Inj.LASIX 20mg IV/OD
ZYTEE GEL for L/A TID
Inj. HAI SC/TID a/c RBS
Tab.DOLO 650mg PO/TID
19/5/23
Inj.PAN 40mg IV/OD
Inj.MONOCEF 1gm IV/BD
Inj. ZOFER 4mg IV/BD
Inj.LASIX 20mg IV/OD
ZYTEE GEL for L/A TID
Inj. HAI SC/TID a/c RBS
Tab.DOLO 650mg PO/TID
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