GM final practical short case

 "This is online E log book to discuss our patients de- identified health data shared after taking his or her guardian's signed informed consent hear we discuss our individual patients problems through a series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This E log book also reflex my patient centered online learning portfolio and your valuable inputs on comment box is welcome."

CHIEF COMPLAINTS:

A 43 yr old female patient came to the OPD with a chief complaint of  lower backache since 2 days , pain abdomen and vomiting since 1 day 

HISTORY OF PRESENT ILLNESS:

Patient was apparantly asymptomatic 6 yrs back , then she developed anasarca went to the local hospital

There she was diagnosed with hypothyroidism (started on tab.Thyronorm 50 microgram) &  also DM  ( started on injection MIXTARD ) and  also got diagnosed for renal failure & was on tab.Torsemide 20 mg+ spironolactone 50mg .

Patient complaints of pain abdomen which is intermittent in nature associated with vomitings (2 episodes).

No history of fever, cold, cough, loose stools, constipation, Malena, haematuria.

No history of pedal edema, 

decreased urine output, facial puffiness.

PAST HISTORY:

Patient is known case of DM since 6 yrs

Patient is also known case of hypothyroidism since 6 yrs

No history of hypertension, CAD , asthma, epilepsy, tuberculosis.

PERSONAL HISTORY:

Diet : mixed

Appetite : decreased 

Sleep : adequate

Bowel& bladder movements : regular 

No addictions. 

FAMILY HISTORY:

Patient mother is a known case of diabetes mellitus.

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative well oriented to time, person and place. 

No pallor , icterus, cyanosis, clubbing , generalized lymphadenopathy.

VITALS:

Temperature -  Afebrile 

Bp-150/80 mm hg

Pulse rate -  88bpm

Respiratory rate - 21cpm

Spo2- 99% on RA

SYSTEMIC EXAMINATION : 

RS- decreased breath sounds on

Cvs-S1 S2 +

P/A - soft, diffuse tenderness + 

Cns- No abnormality

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS : 

pain abdomen secondary to uncontrolled sugars with DKA with ? (CKD secondary to metabolic acidosis ) with metabolic acidosis secondary to DKA & CKD with H/o DM, hypothyroidism , CKD

TREATMENT :

1) IVF – 0.9% NS @ 150ml/hr

2) INJ. PANTOP 40mg IV/OD

3)INJ.ZOFER 4mg IV/TID 

4) INJ. METROGYL 500MG /IV / TID

5) INJ. TRAMADOL 1AMP IN 100 ML NS /IV/TID 

6)INJ. INSULIN INFUSION WITH 2ML/HR 

7)INJ.BUSCOPAN 2CC IV/SOS

8)INJ.LASIX 40MG IV/BD

9) TAB.THYRONORM 50microgram PO/OD