45 Goli Shreya , 5th semThis elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio.
CASE45 Goli Shreya , 5th sem
This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio.
CASE- This is a case of 50 year old female who came with chief complains of left lower back pain and vomitings from morning
CHIEF COMPLAINTS
- Lower back pain on the left side from morning 4 am.
- Vomitings from morning
- Constipation since 3 days
Date of admission : 22.07.2022
HISTORY OF PRESENT ILLNESS- Patient was asymptotic 13 years back which when she had complaints of generalised weakness, polyuria ,blurring of vision followed by unconsciousness for which hi she was taken to hospital.
- There she was diagnosed with diabetes for which she was given insulin injection and has been taking the injection on daily basis.
- But again, One and half yr back she developed polyuria , incidents of closing of eyes , weakness for which she went to hospital and the doctor had prescribed medication along with injection
- Again, 15 days back she hit her head to the fridge and had developed one side headache .
- She was bought to our hospital complaining about polyuria , headache and also loss of consious for which she was diagnosed with DKA (diabetic keto acidosis) and was treated for the same .
- After one day stay at home , the next day at morning 4 am she had developed pain on her left loin which she complained about it radiating to the back .
- The pain was described as to the dragging type of pain.
- She was then admitted in our hospital on 22 july .
- She also had developed low grade fever associated with chills which relieved on medication.
- She had two episodes of non projectile and non bilious type of vomiting , contents which included food and milk.
- She also had constipation since three days and complaints of irregular bowel movements since 3 months now, describing that hard stools with blood was seen sometimes.
HISTORY OF PAST ILLNESS- No h/o chest pain / giddiness/ syncope/ cough
- K/c/a DKA since 15 days.
- k/c/o of Diabetes Mellitus since 13 yrs
- No history of hypertension , asthma , seizures , TB , CAD
DAILY ROUTINE
- she is a housewife, wakes up at 5 o clock in the morning.
- She does her morning routine and household chores and has her breakfast at 10 am
- She the takes rest and then has her lunch at 2 pm and relaxes and has her evening snacks and night dinner at 9 o clock she sleeps by 10 pm.
PERSONAL HISTORY.
- Appetite is Reduced
- Diet - Vegetarian
- Bowels - Irregular
- Micturition - Increased Frequency (Polyuria)
- Allergic to Chanaga pappu (Chana Dal)
- No habits or addictions.
FAMILY HISTORY
Father is known case of Diabetes
TREATMENT HISTORY- Hysterectomy done 13 years back.
- Insulin injections from 13 years.
- Diabetic medication from One and half year.
OBSTETRIC HISTORY
- 3 children
- 3 gravida 3 para 3 live
- One boy and two girls
Physical Examination Pallor: - Seen.
Icterus: - Not Seen
Cyanosis - Not seen
Clubbing - Not seen
Lymphadenopathy - Not seen
Edema of foot - Not Seen
VITALS :
- Temperature – febrile
- Pulse rate –124 per min
- BP –160/80 mm of hg
- Respiration rate –24
- GRBS – 327
- SPO - 98 percent
SYSTEMIC EXAMINATION
1. CVS - No Thrills
- Cardiac sounds S1,S2
- No murmurs
2. RESPIRATORY
- Dyspnoea - absent
- Wheeze - absent
- Position of trachea - central
- Breath sounds are vesicular
3. ABDOMINAL EXAMINATION
- Abdomen - scaphoid shape
- Tenderness present left loin
- No palpable mass
- Hernial orifices normal
- free fluid absent
- No bruits
- Liver is not palpable
- Spleen is not palpable
- Bowel sounds heard
4. CNS - Conscious, coherent and cohesive.
- Speech is normal
- Signs of meningeal irritation- no neck stiffness
- No kernigs Investigations ordered
INVESTIGATIONS
2D Echo
Blood culture
14/7/2022
15/7/2022
16/7/2022
USG
ECG
MONITORING
PROVISIONAL DIAGNOSIS
Diabetic keto acidosis secondary to sepsis caused by bilateral pyelonephritis
TREATMENT
1) normal diabetic diet
2)inj HAI
3) inj NPH
4) inj meropenam 1gm/ ml / BD
5) TAB nitrofurontion
6) IVF NS and RL 75 ml / hr
7) inj neomol 100ml
8) Tab naxdom250 mg
9) Tab orofer
10) TAb b - complex
11) vital monitoring
45 Goli Shreya , 5th sem
This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio.
CASE- This is a case of 50 year old female who came with chief complains of left lower back pain and vomitings from morning
CHIEF COMPLAINTS
- Lower back pain on the left side from morning 4 am.
- Vomitings from morning
- Constipation since 3 days
Date of admission : 22.07.2022
HISTORY OF PRESENT ILLNESS
- Patient was asymptotic 13 years back which when she had complaints of generalised weakness, polyuria ,blurring of vision followed by unconsciousness for which hi she was taken to hospital.
- There she was diagnosed with diabetes for which she was given insulin injection and has been taking the injection on daily basis.
- But again, One and half yr back she developed polyuria , incidents of closing of eyes , weakness for which she went to hospital and the doctor had prescribed medication along with injection
- Again, 15 days back she hit her head to the fridge and had developed one side headache .
- She was bought to our hospital complaining about polyuria , headache and also loss of consious for which she was diagnosed with DKA (diabetic keto acidosis) and was treated for the same .
- After one day stay at home , the next day at morning 4 am she had developed pain on her left loin which she complained about it radiating to the back .
- The pain was described as to the dragging type of pain.
- She was then admitted in our hospital on 22 july .
- She also had developed low grade fever associated with chills which relieved on medication.
- She had two episodes of non projectile and non bilious type of vomiting , contents which included food and milk.
- She also had constipation since three days and complaints of irregular bowel movements since 3 months now, describing that hard stools with blood was seen sometimes.
HISTORY OF PAST ILLNESS
- No h/o chest pain / giddiness/ syncope/ cough
- K/c/a DKA since 15 days.
- k/c/o of Diabetes Mellitus since 13 yrs
- No history of hypertension , asthma , seizures , TB , CAD
DAILY ROUTINE
- she is a housewife, wakes up at 5 o clock in the morning.
- She does her morning routine and household chores and has her breakfast at 10 am
- She the takes rest and then has her lunch at 2 pm and relaxes and has her evening snacks and night dinner at 9 o clock she sleeps by 10 pm.
PERSONAL HISTORY.
- Appetite is Reduced
- Diet - Vegetarian
- Bowels - Irregular
- Micturition - Increased Frequency (Polyuria)
- Allergic to Chanaga pappu (Chana Dal)
- No habits or addictions.
FAMILY HISTORY
Father is known case of Diabetes
TREATMENT HISTORY
- Hysterectomy done 13 years back.
- Insulin injections from 13 years.
- Diabetic medication from One and half year.
OBSTETRIC HISTORY
- 3 children
- 3 gravida 3 para 3 live
- One boy and two girls
Physical Examination
Pallor: - Seen.
Icterus: - Not Seen
Cyanosis - Not seen
Clubbing - Not seen
Lymphadenopathy - Not seen
Edema of foot - Not Seen
VITALS :
- Temperature – febrile
- Pulse rate –124 per min
- BP –160/80 mm of hg
- Respiration rate –24
- GRBS – 327
- SPO - 98 percent
SYSTEMIC EXAMINATION
1. CVS
- No Thrills
- Cardiac sounds S1,S2
- No murmurs
2. RESPIRATORY
- Dyspnoea - absent
- Wheeze - absent
- Position of trachea - central
- Breath sounds are vesicular
3. ABDOMINAL EXAMINATION
- Abdomen - scaphoid shape
- Tenderness present left loin
- No palpable mass
- Hernial orifices normal
- free fluid absent
- No bruits
- Liver is not palpable
- Spleen is not palpable
- Bowel sounds heard
4. CNS
- Conscious, coherent and cohesive.
- Speech is normal
- Signs of meningeal irritation- no neck stiffness
- No kernigs Investigations ordered
INVESTIGATIONS
2D Echo
Blood culture
14/7/2022
USG
ECG
MONITORING
PROVISIONAL DIAGNOSIS
Diabetic keto acidosis secondary to sepsis caused by bilateral pyelonephritis
TREATMENT
1) normal diabetic diet
2)inj HAI
3) inj NPH
4) inj meropenam 1gm/ ml / BD
5) TAB nitrofurontion
6) IVF NS and RL 75 ml / hr
7) inj neomol 100ml
8) Tab naxdom250 mg
9) Tab orofer
10) TAb b - complex
11) vital monitoring
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