GENERAL MEDICINE E-LOG

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

CHIEF COMPLAINT:

A 45 year old male, farmer by occupation came to the opd with the chief complaints of 

• Pain in abdomen since 3 days 
• Nausea since 3 days
• Vomiting, 1 day back 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 years back, then he experienced profuse sweating for which he was taken to a local hospital and was diagnosed to be denovo diabetic and back then his blood sugars were 600mg/dl according to his wife and he was started on Inj. Human Insulin.

Over the past 2 years - he got admitted thrice with similar complaints of Pain in the abdomen, nausea and was diagnosed with acute pancreatitis.

1 year back, Patient had giddiness and fell on his right knee, back then he was taken to a local hospital and was told to have hypoglycemia and his Insulin doses were reduced.

Since the past 1 year,  he continued experiencing right knee joint pains for which he paid a visit to multiple hospitals but wasn't relieved of the pain

Since 3 days, he has been experiencing continuous pain in the abdomen in his epigastrium and left hypochondriac region, which doesn't get relieved on sitting posture but is aggravated on eating food along with this he also has been experiencing nausea.

He also had 1 episode of vomiting which was non projectile, non bilious, non blood tinged Vomiting with food content.

HISTORY OF PAST ILLNESS:

He is a known case of Type 2 Diabetes mellitus since 2 years.

TREATMENT HISTORY:

He is denovo diabetic since 2 years for which he is treated with Insulin for the past 2 years.

PERSONAL HISTORY:

Patient works as a farmer along with his wife at nalgonda. He has 2 kids. He has been a regular alcoholic since the past 20 years with a daily intake of 90 to 180 ml of whiskey per day. He stopped consuming alcohol 1 month back. He also chews tobacco, atleast 2 times per day.

GENERAL EXAMINATION:

Patient is conscious, he is a thin built man

 

Pallor is present

Absence of Icterus, Clubbing, Cyanosis, Pedal edema, Lymphadenopathy.

VITALS:

1.Temperature: Afebrile

2.Pulse rate: 70 beats per min

3.Respiratory rate: 18 cycles per min 

4.BP: 110/70 mm Hg

5.SpO2: 99% @ Room air 

6.GRBS: 472mg/dl

SYSTEMIC EXAMINATION: 

CARDIOVASCULAR SYSTEM:

• S1, S2 heard
• No thrills, No murmurs

RESPIRATORY SYSTEM:

• Normal vesicular breath sounds
• Position of trachea is central
• Dyspnoea is absent
• No wheeze

EXAMINATION OF ABDOMEN:

• Shape- scaphoid
• Tenderness is present in epigastrium and right hypochondriac region
• No palpable pass
• Normal hernial orifices 
• No free fluid
• No Bruits
• Liver is not palpable
• spleen is not palpable
• Bowel sounds heard

CENTRAL NERVOUS SYSTEM:

• Patient is conscious 
• Speech is normal 
• No focal neurological defect

PROVISIONAL DIAGNOSIS:

DIABETIC KETOACIDOSIS - known case of Type 2 DM since 2 years

CHRONIC PANCREATITIS

INVESTIGATIONS:

                                     

Chest X-ray 

Urine for Ketone bodies

ECG

ABG:

PH - 7.33

Hco3 - 9

Pco2 - 19

Po2 - 111

Serum Amylase - 28

Lipase - 14

                              

Ultra sound report- It shows atrophied pancreas

with calcifications

TREATMENT :

1. IVF 20NS  100ml/hr

          20RL  100ml/hr

2. Inj. PAN 40mg IV/OD 

3. Inj. ZOFER 4mg IV/TLD

4. Inj. TRAMADOL 50mg in 100ml NS IN/TLD

5. STRICT I/O CHARTING 

6. Inj. THIAMINE 1amp in 100ml/NS/IN/OD

7. Inj. HAI SC/TLD 

          8am-2pm-8pm 

8. BP/PR/RR/SpO2 CHARTING 4th hrly

                             GRBS 4th hrly