A 55year old female wih uncontrolled diabetes.
This is an a 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.
She then visited our hospital on 7/7/22 with complaints of pain abdomen, fever, generalized weakness further evaluated and was diagnosed as diabetic ketoacidosis and was treated accordingly and discharged.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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.This is an a 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.
Aruna.J
Roll no.61
Case report
A 50 year old female homemaker came with chief complaints of fever, low back pain, pain abdomen, 2 episodes of vomiting since 1 day.
HOPI :
Patient was apparently asymptomatic 12 years then she developed symptoms like polydypsia, polyuria and then was diagnosed with Type 2 diabetes mellitus.
She was on regular medication since then.
She developed fever 1 day back which is intermittent type of fever with chills and rigor, not associated with cough and cold which relieves on taking medication.
She also had diffuse abdominal pain which is dull aching type with no aggravating and relieving factors with associated symptoms of 2 episodes of vomiting non bilious, non projectile, food and milk as contents, constipation since 3 days.
She was having similar episodes of (vomiting, pain abdomen, fever ) since 1 year and thus frequently visited hospitals and was accordingly treated.
2 months back patient complained of generalized weakness and further evaluated and was diagnosed with right pyelonephritis and treated conservatively.
Timeline
History of past illness
she developed lower abdominal pain for which she was evaluated and diagnosed with a fibroid for which hysterectomy was done 11 years back.
Daily routine
Patient wakes up at 6 AM in the morning freshens up drinks milk and has breakfast at 9 AM then she does little bit of household chores, takes lunch at 1 PM then takes rest for an hour or so and has milk at 6 PM, dinner at 8:30 PM and sleeps at 9:30 PM.
Past history
H/o Diabetes mellitus since 12 years.
No H/o Hypertension, CAD, asthma, epilepsy, tuberculosis.
No previous history of blood transfusions.
H/o hysterectomy 12 years back.
Personal history
Diet is vegetarian with normal appetite and regular bladder movements, sleep is adequate, and constipation since 3 days.
No addictions.
No drug allergies.
General examination
Patient is conscious, coherent and cooperative, well oriented to time, place and person.
No features indicating the presence of pallor, icterus, cyanosis, clubbing, lymphadenopathy, generalized edema.
Blood pressure 140/80 mmHg
Respiratory rate 18cpm
Pulse rate 85bpm
Temperature febrile
Systemic examination
CVS- S1 and S2 heart sounds heard.
RS- Bilateral air entry is present, normal vesicular breath sounds heard.
ABDOMINAL EXAMINATION
INSPECTION
Shape - Scaphoid, with no distention.
Umbilicus - Inverted
Equal symmetrical movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.
PALPATION
No local rise of temperature
Abdomen is soft with tenderness in the left loin region.
No spleenomegaly, hepatomegaly.
PERCUSSION
Liver span is 12cm.
No hepatomegaly
Fluid thrill and shifting dullness absent.
No puddle sign.
AUSCULTATION
Bowel sounds present.
No bruit or venous hum
CNS examination
Higher motor functions intact
No focal neurological deficits noted.
Provisional diagnosis
Diabetic ketoacidosis
Urinary tract infection
Treatment
Comments
Post a Comment