35 Y/O male with complaints of vomitings

 35 year old male patient with vomitings  since 1 day


9th March 2023 


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35year old male patient with vomitings since 1 day


Dr. M. Prathyusha ( Intern )


Roll no : 96


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.


CASE :  

35 year old male patient  came to casualty with complaints of 

1. Vomitings since 1 day

HOPI : 

Patient was apparently asymptomatic  untill yesterday morning then he had 6 episodes of vomitings yesterday and 7 episodes today, non projectile ,non bilious,with food particles as contents ,not blood tinged .

He then went to local hospital and got medication but his nausea and vomitings did not reduce and then he came to our hospital.

No c/o pain abdomen ,fever,chest pain, sob

10 days back there is h/o weakness of upper and lower limbs for which he visited hospital and was told that he has poor glycemic control since 10 days ,he quit alcohol and started taking medication regularly.

PAST HISTORY :

No similar complaints in the past 

K/c/o diabetes type  II since 2 yrs on ( tab.glimiperide 1 mg and tab.metformin 500 mg + tab. Voglibose 0.2 mg )

K/c/o HTN since 4 yrs on regular medication ( unknown)

Not a k/c/o TB ,epilepsy, asthma,CAD,CVD, thyroid disorders.


PERSONAL HISTORY:

Appetite-  decreased from 2 months 

Diet - mixed 

Bowel - constipation present 

Bladder - normal 

Addictions - last intake-10 days ago consumed brandy 1 L per day 

Smoking (3 per day) stopped 5 yrs ago

FAMILY HISTORY:

No significant family history 


GENERAL EXAMINATION:-

Pt is C,C,C 

No icterus , cyanosis, clubbing, lymphadenopathy , pedal edema 








Vitals - 

Temp -98.4F

PR - 139bpm

BP - 130/80mmhg

RR - 20cpm

SpO2 - 94% at Room air 

GRBS-341mg/dl


SYSTEMIC EXAMINATION :

PER ABDOMEN :

Inspection :

Umbilicus is central and inverted

All quadrants are moving equally with respiration 

No sinuses , engorged veins, visible pulsations .

Hernial orifices are free


Palpation :

Abdomen is soft in consistency.

No organomegaly.

Liver and Spleen - Not palpable 


Percussion : Tympanic note heard over the abdomen.

Auscultation:Bowel sounds are heard.


CARDIOVASCULAR SYSTEM:

Inspection:

Shape of chest is elliptical. 

No raised JVP

No visible pulsations, scars , sinuses , engorged veins.


Palpation:

Apex beat - felt at left 5th intercostal space

No thrills and parasternal heaves


Auscultation :

S1 and S2 heard. 


RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 


Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal


Percussion: resonant bilaterally 

Auscultation:

bilateral air entry present. Normal vesicular breath sounds heard.


CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes - Right.  Left

Biceps.      ++        ++

Triceps.    ++         ++

Supinator ++.       + +

Knee          ++         ++

Ankle.          ++      ++

INVESTIGATIONS:-

BLOOD UREA-


LFT-



SERUM ELECTROLYTES-


HEMOGRAM -


CUE-


SERUM CREATININE -


URINE FOR KETONE BODIES - POSITIVE


ABG:-



ECG:-



USG ABDOMEN:-



CHEST XRAY:-


PROVISIONAL DIAGNOSIS : 

?Diabetic ketosis


TREATMENT : 

1.IVF NS bolus f/b 100 ml/hr

2. INJ. HUMAN ACTRAPID INSULIN 10U S/C@10 pm

3. INJ.NPH  4U @ 10:30pm

4. INJ.PAN 40 MG IV/STAT

5. INJ.ZOFER 4MG IV/STAT

6. INJ. THAIMINE 200mg IV BD


SOAP NOTES:-

20/3/23

AMC BED NO.2

Unit-6

Dr.Abhinaya(SR)

Dr.Shashikala(PGY3)

Dr. Manasa (PGY3)

Dr.Keerthi(PGY2)

Dr.Nithin(PGY1)

Dr.Prathyusha(Intern)

Dr.Ankitha(Intern)


Nausea and vomitings subsided 

pain abdomen reduced , stools  passed today 

O

Pt is conscious , coherent , cooperative

BP-130/90mmhg 

PR- 84bpm

Temp- 97.8F

RR -20cpm

GRBS-175mg/dl

CVS- S1,S2 heard, no murmurs 

RS- BAE (+), NVBS(+)

P/A-soft, non-tender , no organomegaly

Bowel sounds(+)

CNS: NAD 

A

Diabetic ketosis secondary to starvation with prerenal AKI with hypertension 

P

1.IV FLUIDS-  NS ,RL 

2.INJ. PANTOP 40 mg IV OD

3.INJ. ZOFER 4MG IV/SOS 

4 .INJ.THIAMINE 200mg in 100 ml NS iv TID

5. INJ . HUMAN ACTRAPID INSULIN S/C TID

6. INJ.NPH S/C BD ACCORDING TO GRBS

7.GRBS MONITORING 2 ND HRLY

8.VITALS MONITORING 4TH HRLY









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