35/F DKA with vomitings, pain abdomen, non healing wound.






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.

CONSENT AND DEIDENTIFICATION :
 
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever.




Patient came with complaints of vomitings since 4 days, pain and  burning sensation in epigastrium since 4 days, 

Non healing wound over left foot since 3 months

Patient was apparently asymptomatic 7 days back then developed vomitings sudden in onset non bile stained, non projectile, vomitings associated with pain epigastrium and difficulty in breathing.

No h/o cough /cold/ fever/ diarrhea / burning micturition.


K/C/O Diabetes mellitus type II on medication T. Glimstar M1 BD 

No H/O HTN , TB, Asthma, epilepsy.


Personal History

Housewife by occupation 

Appetite : lost

Diet: Mixed

Bowels and Bladder: Regular

No Addictions

General Examination:


Patient is C/C/C

No Pallor,Icterus, Cyanosis, Lymphadenopathy,Edema.

Temp: 98.6

PR:80

RR: 30

BP: 100/60 

SpO2 95 at room air

GRBS: 596

Systemic Examination:

CVS: S1 S2 Heard, No murmurs

RS: BAE present, No adventitious sounds

CNS:No FND

Per Abdomen: Soft Non tender, No organomegaly


Ortho referral was done i/v/o left foot osteomyelitis.

Advice: Cbp, esr , CRP ,

Xray left foot AP and Oblique

PUS - C\s


Surgery Referral was done



Investigations:
































SURGERY REFERRAL












ORTHO REFERRAL







OPHTHALMOLOGY REFERRAL






Treatment:

1) IV fluids 0.45 % NS + 5 % Dextrose at 50 ml/ hr
2)INJ PITAZ 4.5 gm IV /TID
3) INJ Clindamycin 600 mg IV/ TID
4) INJ PAN 40 mg IV/BD
5) INJ ZOFER 4mg IV / BD
6) INJ HUMAN ACTRAPID INFUSION S/C TID ACCORDING TO GRBS







Comments

Post a Comment

Popular posts from this blog

My Journey as an Intern In Medicine

Image
I am Sanjana Thota, Intern posted in the General Medicine Department from 1/12/23 until 31/1/24. “To cure sometimes, to relieve often, to comfort always.”- Edward Livingston Trudeau.  1) Self Reflection on my Medical Career: My first case taken in the manner if an e-log during my 2nd year Medicine Posting. https://sanjanathotarollno141.blogspot.com/2022/09/a-70-yr-old-female-with-involuntary.html?m=1 Through this process, I learned how to document the process of history taking, diagnosis, investigations and the treatment of a patient. During my internship, I came across cases such as DKA, Heart Failure, CKD, SLE, Septic Shock,CVA, Epilepsy and common chronic diseases such as Diabetes, Hypothyroidism and Hypertension. I witnessed an episode of GTCS and the acute management of such a case in the ICU. I also learned how to diagnose and further evaluate a case of MI / ACS.I learned about spinal cord lesions, how to perform a full CNS examination and how to localize a stroke. My journey in
Read more

60 y/o male with hypertension, heart failure and decreased urine output.

Image
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have 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 diagnosis and treatment plan. Patient was apparently asymptomatic 3 months ago, then he developed b/l pedal edema, initially extending only up to the ankles, which gradually progressed up to both the thighs, over the last 15 days. Patient c
Read more

A 70 yr old female with involuntary movements in upper and lower limb

Image
MEDICINE E LOG BOOK This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have 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 diagnosis and treatment plan. CHIEF COMPLAINT Altered sensorium since 12:00 am midnight, involuntary movement in upper and lower limb since 12:00 am, loss of speech after 12:00 am HISTORY OF PRESENTING ILLNESS Pt was app
Read more