A 50 yr old male ,farmer by occupation

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 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.

CASE 

A 50 yr old male patient, resident of narketpally,farmer by occupation came to casuality with c/o

-Epigastric pain since 1 week
-Vomitings (4 to 5 episodes)/ day since 1 week subsided now
-C/o loose stools (7 to 8 times / day since 1 week subsided now


Pt was apparently asymptomatic 1 month back,he had an history of trauma (injury by crow bar )for which he developed an ulcer over his left lower limb for which he came to the hospital and was diagnosed as diabetic and hypertensive  but was not on any treatment .1 week back pt developed epigastric pain since 1 week which is diffuse and non radiating and of squeezing type.pt also complains of vomitings 
(4 to 5 episodes)/ day since 1 week - non bilious ,non projectile with food particles as content presently subsided which is associated with loose stools 7 to 8 times / day since 1 week  presently subsided.

C/o fever , low grade fever , intermittent since 4 days not assocaited with chills , rigor and also decreased appetite.

No h/ o cough,cold,shortness of breath,chest pain ,pedal edema 
H/ o burning micturition 


Past history:
No history of any similar complaints in the past 
No history of any surgeries 
No history of asthma ,epilepsy,CVA or CAD

Denovo detected DM 2 ,Denovo detected  hypertension 

Personal history
Diet - mixed
Appetite- decreased
Sleep- adequate
B,B- regular, normal

chronic alcoholic since 30 yrs ( 180 ml/ day- whisky)
Chronic smoker since 30 yrs
( 10 beedis/ day)

General examination
Pt c/c/c 
Vitals 
Afebrile
Bp- 110/70 mmhg
Pr- 82bpm
Rr- 18cpm
Spo2- 98% on ra 
No pallor, icterus, cyanosis, clubbing, lymphedenopathy, pedal edema





Ulcer  over left lower limb which got healed currently by proper dressing.

Systemic examination: 

CVS: s1, s2 +
RS: BAE+, NVBS+
P/A - soft , distended hepatomegaly, non tender
CNS- no focal neuralogical deficit

Provisional diagnosis:
?Uncontrolled sugars tor/o DKA
? Chronic pancreatitis
Denovo DM( Type 3c) , HTN


INVESTIGATIONS:

On day of admission : 

HEMOGRAM
Hb - 14.5
TLC- 7000
PlT - 1.68
CUE- sugars++++
Urine for ketone bodies: - ve

RBS- 336

Blood urea- 16

Serum creatinine- 0.8

 
Serum electrolytes 

Na+ 137
K+ 4
Cl-102


LFT
TB- 0.83
DB- 0.21
AST- 41
ALT - 33
ALP- 201
TP- 6.5
ALB- 3.99


HBA1C- 7.4

 Serum amylase- 44

 Serum Lipase- 29

ECG : 
2d echo 

Chest xray : 





On 15/9/21 

FLP : 
Cholesterol - 134 
TGL - 166
HDL - 40 
LDL - 78
VLDL - 33.2 




Day 1 : 

1)IVF - 2 NS AND 2 RL @100ml/hr 
2)INJ.THIAMINE 100MG IN 100 ML NS  IV/TID
3)INJ .HAI S/C - GRBS
        8AM - 2PM- 8PM
4)INJ.PAN 40 MG /IV/OD
5)INJ.ZOFER 4 MG IV/TID
6)T.AMLONG 10 MG /PO/OD 
7)TAB.SPOROLAC PS /PO/TID
8)INJ.CEFTRIAXONE - 1GM /IV/BD 
9)MONITOR VITALS 
10)GRBS CHARTING 
11) INFORM SOS 

Day 2 : 
  
Ultra sound report : 

1)IVF - 2 NS AND 2 RL @100ml/hr 
2)INJ.THIAMINE 100MG IN 100 ML NS IV/TID
3)INJ .HAI S/C - GRBS
        8AM - 2PM- 8PM
4)INJ.PAN 40 MG /IV/OD
5)INJ.ZOFER 4 MG IV/TID
6)T.AMLONG 10 MG /PO/OD 
7)TAB.SPOROLAC PS /PO/TID
8)INJ.CEFTRIAXONE - 1GM /IV/BD 
9)MONITOR VITALS 
10)GRBS CHARTING 
11) INFORM SOS 


Day 3 : 


1)IVF - 2 NS AND 2 RL @100ml/hr 
2)INJ.THIAMINE 100MG IN 100 ML NS IV/TID
3)INJ .HAI S/C - GRBS
        8AM - 2PM- 8PM
4)INJ.PAN 40 MG /IV/OD
5)INJ.ZOFER 4 MG IV/TID
6)T.AMLONG 10 MG /PO/OD 
7)MONITOR VITALS 
8)GRBS CHARTING 
9) INFORM SOS 



Discharge summary :

A 50 yr old male patient, resident of narketpally,farmer by occupation came to casuality with c/o

-Epigastric pain since 1 week
-Vomitings (4 to 5 episodes)/ day since 1 week subsided now
-C/o loose stools (7 to 8 times / day since 1 week subsided now


Pt was apparently asymptomatic 1 month back,he had an history of trauma (injury by crow bar )for which he developed an ulcer over his left lower limb for which he came to the hospital and was diagnosed as diabetic and hypertensive but was not on any treatment .1 week back pt developed epigastric pain since 1 week which is diffuse and non radiating and of squeezing type.pt also complains of vomitings 
(4 to 5 episodes)/ day since 1 week - non bilious ,non projectile with food particles as content presently subsided which is associated with loose stools 7 to 8 times / day since 1 week presently subsided.

C/o fever , low grade fever , intermittent since 4 days not assocaited with chills , rigor and also decreased appetite.

No h/ o cough,cold,shortness of breath,chest pain ,pedal edema 
H/ o burning micturition 


Past history:
No history of any similar complaints in the past 
No history of any surgeries 
No history of asthma ,epilepsy,CVA or CAD

Denovo detected DM 2 ,Denovo detected hypertension 

Personal history
Diet - mixed
Appetite- decreased
Sleep- adequate
B,B- regular, normal

chronic alcoholic since 30 yrs ( 180 ml/ day- whisky)
Chronic smoker since 30 yrs
( 10 beedis/ day)

General examination
Pt c/c/c 
Vitals 
Afebrile
Bp- 110/70 mmhg
Pr- 82bpm
Rr- 18cpm
Spo2- 98% on ra 
No pallor, icterus, cyanosis, clubbing, lymphedenopathy, pedal edema
Ulcer over left lower limb which got healed currently by proper dressing.
 


Systemic examination: 

CVS: s1, s2 +
RS: BAE+, NVBS+
P/A - soft , distended hepatomegaly, non tender
CNS- no focal neuralogical deficit

Provisional diagnosis:
?Uncontrolled sugars tor/o DKA
? Chronic pancreatitis
Denovo DM( Type 3c) , HTN


INVESTIGATIONS:

On day of admission : 

HEMOGRAM
Hb - 14.5
TLC- 7000
PlT - 1.68
 
CUE- sugars++++
 
Urine for ketone bodies: - ve
 
RBS- 336

 Blood urea- 16

Serum creatinine- 0.8

Serum electrolytes 

Na+ 137
K+ 4
Cl-102

 LFT
TB- 0.83
DB- 0.21
AST- 41
ALT - 33
ALP- 201
TP- 6.5
ALB- 3.99

HBA1C- 7.4
Serum amylase- 44
 Serum Lipase- 29
 ECG : 
 2d echo 

Chest xray : 

 
On 15/9/21 

FLP : 
Cholesterol - 134 
TGL - 166
HDL - 40 
LDL - 78
VLDL - 33.2 


Final diagnosis :

 acute gastroenteritis ?? typhoid 
Denovo hypertension
Denovo diabetes 


 
Treatment given 

1)IVF - 2 NS AND 2 RL @100ml/hr 
2)INJ.THIAMINE 100MG IN 100 ML NS IV/TID
3)INJ .HAI S/C - GRBS
        8AM - 2PM- 8PM
4)INJ.PAN 40 MG /IV/OD
5)INJ.ZOFER 4 MG IV/TID
6)T.AMLONG 10 MG /PO/OD 
7)TAB.SPOROLAC PS /PO/TID
8)INJ.CEFTRIAXONE - 1GM /IV/BD 
9)MONITOR VITALS 
10)GRBS CHARTING 
11) INFORM SOS 


 Advice at discharge : 
1)Inj.human mixtard 
8 am - 16 units 
8 pm  - 10 units 
2)Telma 40 mg PO/OD 

Follow up after 2 weeks 



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