General medicine posting case 1

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 diagnosis and treatment plan

Ch.preethi
Admission number:176050



65 year old women came to causality on 10/01/23 with 
C/o fever since 2days
Productive cough since 2days 
Breathlessness since yesterday 
Giddiness 2days 
Nausea 2days 
HOPI:
Patient was apparently alright 2days ago the she developed low grade fever intermittent in type not associated with chills and rigours, no diurnal variation, relieved on medication 
She was having productive cough with sputum (white colour) 
Associated with chest pain while coughing, giddiness , nausea and headache, no burning micturation, no decrease in urine output 
Patinet had two episodes of breathlessness yesterday evening and today morning 
Where she was having productive cough with breathlessness, where her both upper limbs and lower limbs became stiff,closed her eyes, passed urine and stools on the bed.

PAST HISTORY:
She had similar episode 1 year ago and was admitted in our hospital in the month of January’2022 
She is known case of HTN and DM since 6 years.
On medication, Metxl 25mg, Atorvastatin 10mg, Glimi M2
No h/o TB in the past 

MENSTRUAL HISTORY:
Age of menarche: 13 years
Age of menopause: 50 years

PERSONAL HISTORY:
Appetite: normal. 
Diet: mixed
Bowel and bladder: regular
Sleep: adequate
Addictions: she has addiction of beedi smoking started at age of 35 years and stopped at the age of 60 years.
No of beedi smoked per day: 2-3 beedi
FAMILY HISTORY:
Her brother had daibetes and hypertension and passed away due to their complications .

GENERAL EXAMINATION:
Patient is concious coherent and cooperative 
Pallor: absent
Icterus:abesnt
Cyanosis:absent
Clubbing: absent 
Lympadenopathy:absent
Edema:absent
VITALS: 
Temp: 96.1F
Bp:120/70mmhg
PR:72bpm
RR:16cpm
Spo2:97
GRBS:223mg/dl

SYSTEMIC EXAMINATION:
Respiratory- B/L air entry present; dyspnea present ; b/L wheeze present 
CVS- s1s2+ no murmur 
P/A soft non tender 
CNS- conscious and oriented

Investigations:
ECG on 10/01/23
x ray on 10/01/23



P

1. IVF- NS @75ml/hr
2. Inj. Pan 40mg IV/OD
3.Inj. Zofer 4mg/IV/TID
4.inj.Neomol 100ml/iv / sos if temp>102F
5.INJ human Actrapid insulin iv infusion @6ml/hr
6.GRBS charting hourly 
7.tab.Dolo 650 mg/po/sos
8.Temp charting hourly
9.vitals monitoring 2nd hourly
10.NEB DUOLIN 8th hourly
               BUDECORT 12th hourly 
11.syp.GRILLINCTUS 8ml/po/TID(10ml)

1. IVF- NS @75ml/hr
2. Inj. Pan 40mg IV/OD
3.Inj. Zofer 4mg/IV/TID
4.inj.Neomol 100ml/iv / sos if temp>102F
5.INJ human Actrapid insulin iv infusion @6ml/hr
6.GRBS charting hourly 
7.tab.Dolo 650 mg/po/sos
8.Temp charting hourly
9.vitals monitoring 2nd hourly
10.NEB DUOLIN 8th hourly
               BUDECORT 12th hourly 
11.syp.GRILLINCTUS 8ml/po/TID(10ml)

On 13Date : 13/01/23

S 
O
Patient is conscious, coherent and cooperative 
BP-120/80mmhg 
PR-86bpm 
CVS- s1s2 heard ; no murmurs 
RS-b/L air entry present ; dyspnea present,non vesicular breath sounds present.
Per abdomen :soft non tender
CNS-HMF +


Investigations:

PLBS: 290mg/dl

Diagnosis:
Viral pyrexia with dengue NS postive.with thrombocytopenia with hypertension since 2 years with T2 DM since 6 years ?heart failure secondary to CAD.
Fever-subsided
Passed stools


P
1. IVF- NS @100ml/hr
2. Inj. Pan 40mg IV/OD
3.Inj. Zofer 4mg/IV/SOS
4.inj.Neomol 1gm/iv/ sos if temp>102F
5.INJ human Actrapid insulin SC according to GRBS
8.tab.Dolo 650mg/po/TID
9.tab.Atorvas 20mg/PO/H/S
10.nebulisation with Duolin 8th hourly and budeocort 12th hourly 
11.Syp.Grillinctus BM/PO/TID
9.Temp charting 4th hourly
10.vitals monitoring 2nd hourly
7.GRBS charting 4th hourly



Date : 14/01/23

S 
Headache subsided
No bleeding manifestations and giddiness decreased.
Stools passed today

O
Patient is conscious, coherent and cooperative 
BP-160/90mmhg 
PR-94bpm 
CVS- s1s2 heard ; no murmurs 
RS-b/L air entry present ; dyspnea present,wheeze present.
Per abdomen :soft non tender
CNS-concious and oriented

  Investigations:
Hb-12.8
TLC-6400
Plt- 40000


Diagnosis:
Viral pyrexia with dengue NS1 positive with thrombocytopenia with hypertension since 2 years withT2DM since 2 years with seizures under evaluation.



P
1. IVF- NS @75ml/hr
2. Inj. Pan 40mg IV/OD
3.Inj. Zofer 4mg/IV/TID
4.inj.Neomol 1gm/iv / sos if temp>101F
5.INJ human Actrapid insulin s/c
10U-10U-10U
6.inj.NPH s/c
7.Tab.NITROFURANTOIN 100mg Po/BD
8.Tab.LEVIPIL 500mg/PO/BD
9.Tab.dolo 650mg/PO/TID
10.Tab.Atorvas 20mg/PO/TID
11.Tab.TELMA 40mg/PO/OD
11.syp.GRILLINCTUS BM/PO/TID
12.NEB DUOLIN 8th hourly
BUDECORT 12th hourly .
13.GRBS charting 4th hourly 
14.Temp charting 4thhourly
15.vitals monitoring 2nd hourly

Saop saidamma
Date : 16/01/23
Ward
Unit 2 
S 
Headache subsided
No bleeding manifestations and giddiness decreased.
Stools passed today

O
Patient is conscious, coherent and cooperative 
BP-150/90mmhg 
PR-88bpm 
CVS- s1s2 heard ; no murmurs 
RS-b/L air entry present .
Per abdomen :soft non tender
CNS-concious and oriented

  Investigations:
Hb-12.3
TLC-5600
Plt- 80000
Urea:14
Creatinine:1.0
Na: 137
K:3.2
Cl:101
 24hr urinary
Na: 178
K:12.7
Cl:124
Cr:0.6
Protein:417



Diagnosis:
Viral pyrexia with dengue NS1 positive with thrombocytopenia with hypertension since 2 years withT2DM since  6 years with  history of Tonic seizures( last episode 3months back)



P
1. IVF- NS @100ml/hr
2. Inj. Pan 40mg IV/OD
3.Inj. Zofer 4mg/IV/TID
4.inj.Neomol 1gm/iv / sos if temp>101F
5.INJ human Actrapid insulin s/c
10U-10U-10U
6.inj.NPH s/c
8U-8U
7.Tab.NITROFURANTOIN 100mg Po/BD
8.Tab.dolo 650mg/PO/sos
9.Tab.Atorvas 20mg/PO/HS
10.Tab.amlong 5mg OD .
11.NEB DUOLIN 8th hourly
BUDECORT 12th hourly .
12.GRBS charting 4th hourly 
13.Temp charting 4thhourly
14.vitals monitoring 2nd hourly

Comments

Post a Comment

Popular posts from this blog

INTERNSHIP ASSESSMENT

During ICU duty: 18.2.23 to 23.2.23 1.Learnt CPR 2.Assisted For intubation for  - ICU bed 2- 40year old female (CKD patient) 3. Have taken ABG samples ( femoral, radial ) in both ICU and AMC During ward duty and nephro duty: 24.2.23 to 5.3.23 Monitoring patients  Took venous samples for investigations  During casuality duty: Have taken throat and nasal swabs for rapid and RTPCR covid tests During Unit: - Have placed foleys and rules tube  - Have assisted in performing central line  Case1- http://19preethicheera.blogspot.com/2023/01/general-medicine-posting-case.html Case2-   http://19preethicheera.blogspot.com/2023/01/general-medicine-posting-case-2.html Case3- http://19preethicheera.blogspot.com/2023/01/general-medicine-postings-case-3.html Case4- http://19preethicheera.blogspot.com/2023/02/general-medicine-posting-case-5.html Case-5 http://19preethicheera.blogspot.com/2023/12/diabetic-ketoacidosis-with-old-mi.html Psychiatry posting: 03.02.23 to 17.02.23 Learning experience: - Histor
Read more

80 year old female with SOB and chest pain

Image
CH. Preethi Roll number- 19 4th year MBBS This is an online E-log book to discuss our patient de-identified health data shared after taking his/ her guardians sign informed consent Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve those patient clinical problem with collective current best evidence based inputs. This E-log also reflects my patient centered online learning portfolio. Your valuable inputs on 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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan. A 80 year old female came to casualty with complaints of: -shortness of breath since 2days -generalised weakness since 2days and -chest pain since 1day  History of presenting illnes
Read more

DIABETIC KETOACIDOSIS WITH OLD MI

Image
25year old male painter by occupation since 8  years came tocasuality on 7/2/23 with complaints of c/o fever,vomitings,constipation since 1 week C/ o chest pain, palpitations since 1 week C/o sob since 1week c/o neck pain History of present illness Patient was apparently asymptomatic 9 years back, Patient c/o blurring of visionin right eye for which he went to local hospital used medication eye drops(Rt>>Lt) wasn't subsided  In 2014 patient c/o severe weight loss approximately 10-12 kgs over a duration of 2 months. And having increased appetite, increased frequency of urination with these complaints he went to Local hospital and diagnosed with type 1 diabetes mellitus and since then he was started on Mixtard insulin 28U -x - 24U and since then he is on regular follow up.. 24u- x-20u now he was using  His fbs used to be around 200-250 and ppbs around 250-300 Last HbA1c was 11.2 on feb 3rd  Now since 1 week patient had a fever whichwas sudden in onset high grade associated with
Read more