GENERAL MEDICINE CASE DISCUSSION

68 years old lady with lower abdomen pain & Type II Diabetes



May 14, 2023

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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan .

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

Gynecology refferal
Opthalmology Refferal
Orthopedics Referral
Nephrology Refferal
Gasroenterology Refferal

Old reports

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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