General medicine case discussion

B.Varshitha 
5th semester 
Roll no.21
This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 protfolio and your valuable inputs on comment box is welcome.


A 59year old female patient came to the hospital with cheif complaints of burning micturation since 2months and abdominal pain since 3days 

History of present illness 
Patient was apparently asymptomatic 2months back and she developed burning micturation not associated with fever and 3days back then she developed abdominal pain which is diffuse and 2days back she had 2 episodes of vomitings after meal which is non-projectile and non-bilirous.

History of past illness 
K/C/O epilepsy  (stopped 10years back after using medicines) and still on medication 
K/C/O  Asthma (stopped 6years back)
K/C/O Diabetes since 6years and still on medication 
K/C/O Hypertension since 5years and still on medication 

Family history 
Family history of epilepsy and asthma is present 
No history of HTN, Diabetes, TB

Personal history 
• Diet : mixed
• Appetite: normal 
• Sleep : distributed due to pain
• Bowel habits: normal 
• Bladder habits : burning micturation 
• No Addictions

Physical examination 

General examination 
• No pallor
• No icterus
• No cyanosis
• No lymphadenopathy
• No clubbing of fingers
• Moderately built and moderately nourished.

Vitals
Temperature: Afebrile 
Pulse rate: 88/min
BP:124/82
RR:14/min


SYSTEMIC EXAMINATION

CVS

S1,S2 Heard
No murmurs

RESPIRATORY SYSTEM

No Dyspnea
No wheezes
Trachea-Central
Breath sounds-vesicular

ABDOMEN
No Distended abdomen 
tenderness is present severe in epigastric and right inguinal region
No palpable mass
No free fluid 
No briuts
No palpable spleen and liver


CNS

Conscious
Coherent
Cooperative
Speech-normal
No neck stiffness
Sensory system- Normal
Motor system- normal

PROVISIONAL DIAGNOSIS: diabetes ketosis 

INVESTIGATIONS 
                              ECG 

2D ECHO
ULTRASOUND REPORT 
FINDINGS 

Treatment 
23/06/2022
INJ HAI 6 IU/IV/STAT
INJ HAI IN 39ML NS@6ML/HOUR 
IVF-NS@ 3L/IV BOLUS/ WITHIN 3 HOURS OF ADMISSION 
IVF/NS/RL@150ML/HOUR
INJ PAN 40MG/IV ONCE DAILY 
INJ OPTINEURON 1 AMP IN 100ML NS/IV OVER 30MINS
INJ MONOCEF 1G/IV TWICE DAILY 
GRBS MONITORING HOURLY 
VITALS MONITORING HOURLY 
INFORM SOS
IVF 10% DEXTROSE (IF GRBS <200MG/ML) (INCREASE OR DECREASE ACCORDING TO GRBS)
TAB AMLONG 5MG ONCE DAILY 
SYRUP POTCHOR 5ML  PER ORAL THRICE DAILY 
INJ ZOFER 4MG/IV THRICE DAILY 
                     
24/06/2022

INJ HAI IN 39ML NS@2ML/HOUR
IVF/NS/RL@100ML/HOUR
INJ MONOCEF 1G/IV TWICE DAILY
INJ PAN 40MG/IV ONCE DAILY
INJ OPTINEURON 1 AMP IN 100ML NS/IV OVER 30MINS
INJ ZOFER 4MG/IV THRICE DAILY
TAB AMLONG 5MG PER ORAL ONCE DAILY
SYRUP POTCHOR 15ML  PER ORAL THRICE DAILY
GRBS MONITORING HOURLY 
VITALS MONITORING HOURLY
TAB UDILIV 300MG PER ORAL/ TWICE DAILY 
SYRUP CITRALKA 10ML PER ORAL THRICE DAILY 


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