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-
URINE FOR KETONE BODIES - POSITIVE
ABG:-
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)
S
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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