Gen med case presentation;
Oct 27,2021.
Name;Ramya reddy pebbeti.
Roll no;105 .
This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed 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 patients’ clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome.
I’ve 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
Following is the view of my case :
CASE PRESENTATION ;
DOA; 25/10/21
Chief complaint: A 28 yr old female ,home maker ,came to the opd with a c/o ABDOMINAL DISTENSION Since5 days
HOPI; patient was apparently asymptomatic 5 days back then she noticed the abdominal distension which was insidious in onset,gradually progressive from 5 days, there were no aggravating factors ,relieved on micturition [as she noticed]
there is no h/o abdominal pain,,vomiting,SOB,pedal oedema,decreased urine output,recent jaundice.
she gives h/o weight loss.
PAST HISTORY;
she was diagnosed as TYPE 1 DM in JAN 2021
not a k/c/o HTN,THYROID,ASTHMA,EPILEPSY
PERSONAL HISTORY;
DIET; mixed
appetite;normal
bowel and bladder;regular
sleep ;adequate
no known drug allergies
no history of any addictions
FAMILY HISTORY; not significant
MENSTRUAL HISTORY;
menarche; 15 yrs
cycles ;regular[30 days]
duration of each cycle;3 days
GENERAL EXAMINATION;
she is conscious,coherent,cooperative,well oriented to time ,place,person,
she is thin built,moderately nourished.
VITALS;
PR;87 bpm
BP;110/70
RR;18 cpm
TEMP;98.6 F
SPo2;98% on room air
GRBS;387mg/dl
pallor;present
icterus;absent
koilonychia;absent
clubbing;absent
lymphadenopathy;absent;
edema;absent
SYSTEMIC EXAMINATION;
RS;BAE +
CVS;S1,S2 heard
CNS;INTACT
LOCAL EXAMINATION;
PER ABDOMEN;
Inspection;
shape ;distended
position of umbilicus;EVERTED
movement is equal on all quadrants with respiration
no visible scars,sinuses,engorged veins,pigmentation
Palpation;
no local rise of temperature
no tenderness
spleen ;palpable
liver ;palpable
Percussion;
fluid thrill;positive
shifting dullness;present
Auscultation;
bowel sounds were heard
no bruit heard
PROVISIONAL DIAGNOSIS;
Chronic liver disease
?APLA
TREATMENT;
fluid restriction<1L/day
salt restriction <2gm/day
TAB.lasilactone [20/50mg]/po/BD -8 AM,4PM
TAB.wysolone 20mg/OD 8AM
TAB.pantop 40 mgpo/OD 8AM
INJ,human insulin mixtard 22units mrng 8AM and 16 units night 8PM
GRBS charging 6th hourly [8AM-2PM-8PM-2AM]
daily abdominal girth measurement and weight
monitor vitals
HEMOGRAM;
Hb;8.3g/dl
TLC;4000cells/cumm
platelets;1L/cumm
26/10/21;
SOAP NOTES DAY 2
AMC BED 5
S:
-C/O Abdominal distension
-S/P Ascitic tap done yesterday around 500ml
- did not pass stools yesterday.
O:
-pt is C/C/C
- Afebrile
-No pedal edema
-BP-100/60mmhg
-PR-82BPM
CVS: S1S2 heard
RS: BAE +, NVBS
P/A: Distended
Shifting dullness+
B.S +
Splenomegaly+
Engorged veins:no
ASCITIC FLUID ANALYSIS:
High SAAG-low protein.
SAAG: 2.14
Ascitic protein:1.0
Sugar:472
Amylase:38
LDH: 148.
Sr.LDH-220.
GRBS: 206MG%
Wt:36kgs
Abd girth- 76cms
A:
- CLD secondary to
BUDD CHIARI SYNDROME.
-with K/C/O TYPE 1 DM with
UNCONTROLLED SUGARS.
- with H/O ? APLA.
-? SUB CLINICAL HYPOTHYROIDISM.
P:
1. Fluid restriction<1.5 lit/day
2.salt restriction: <2gm/day
3.T.LASILACTONE 20/50mg /po/OD.
4.T.WYSOLONE 20MG /PO/OD.
5.T.PANTOP 40MG PO/OD
6.INJ. HAI 40IU in 39ml NS @ 6ml/hr.
7. NBM till further orders.
8.GRBS hourly
9.strict I/O charting.
10.BP/PR/TEMP charting.
Review 2D echo;
Glycated hemoglobin:HbA1C ;6.9
27/10/21;
SOAP NOTES DAY 3
AMC BED 5
Case seen by :
Dr.Sai Surya(intern )
Dr.Neha (intern )
Dr.Trishaala(intern )
Dr.Varaprasad(intern )
Dr.Srivalli(intern )
Dr.Harika.K (intern )
Dr.Aashitha PG Y 3
Dr.Nikitha PG Y3
Dr.Usha PG Y 3
Dr.Shashikala PG Y3
Dr.Hareen Sr Resident
Dr.Arjun kumar Ass prof
Dr .Rakesh Biswas HOD
S:
C/O Abdominal distension
No fresh complaints.
O:
Pt is C/C/C
TEMP: 97.6°f
BP: 100/60mmhg
PR:89bpm regular,normal volume
RR:20CPM
CVS: S1S2 +, no murmers.
RS: NVBS + ,no crepts.
P/A: Distended
B.S +
GRBS: 187 '100'
I/O: 1000/850ML
SPO2: 98% @RA
SPLENOMEGALY +
SHIFTING DULLNESS+
PASSED STOOLS +
NO ENGORGED VEINS
WEIGHT: 37KGS
ABD GIRTH-81CMS.
FASTING BLOOD SUGAR: 119MG%
SERUM ELECTROLYTES:
NA: 140
K: 3.7
CL: 104
SERUM OSMOLALITY: 300
HB1AC: 6.9
A:
CLD secondary to
BUDD CHIARI SYNDROME.
-with K/C/O TYPE 1 DM with
UNCONTROLLED SUGARS.
- with H/O ? APLA.
-? SUB CLINICAL HYPOTHYROIDISM
P:
1.Fluid restriction<1.5 lit/day
2.salt restriction: <2gm/day
3.T.LASILACTONE 20/50mg /po/BD.
4.T.WYSOLONE 20MG /PO/OD.
5.INJ. HAI S/C PRE MEAL ACCORDING TO SLIDING SCALE.
6.Wt and Abd girth- daily
7.strict I/O charting.
8.BP/PR/TEMP/GRBS charting.
Serum IgG antibodies sample sent
28/10/21
SOAP NOTES DAY 4
AMC BED 5.
Case seen by :
Dr.Sai Surya(intern )
Dr.Neha (intern )
Dr.Trishaala(intern )
Dr.Varaprasad(intern )
Dr.Srivalli(intern )
Dr.Harika.K (intern )
Dr.Aashitha PG Y 3
Dr.Nikitha PG Y3
Dr.Usha PG Y 3
Dr.Shashikala PG Y3
Dr.Hareen Sr Resident
Dr.Arjun kumar Ass prof
Dr .Rakesh Biswas HOD
S:
C/O Abdominal distension
No fresh complaints.
O:
Pt is C/C/C
AFEBRILE
BP: 100/60mmhg
PR:82bpm regular,normal volume
RR:20CPM
CVS: S1S2 +, no murmers.
RS: NVBS + ,no crepts.
P/A: Distended
B.S +
GRBS: 420MG% 16U
I/O: 700/1050ML
SPO2: 98% @RA
SPLENOMEGALY +
SHIFTING DULLNESS+
PASSED STOOLS +
NO ENGORGED VEINS
WEIGHT: 35KGS
ABD GIRTH-75CMS.
ASCITIC TAP DONE YESTERDAY.
A:
CLD secondary to CIRRHOSIS
-with K/C/O TYPE 1 DM with
UNCONTROLLED SUGARS.
- with H/O ? APLA.
-? SUB CLINICAL HYPOTHYROIDISM
P:
1.Fluid restriction<1.5 lit/day
2.salt restriction: <2gm/day
3.T.LASILACTONE 20/50mg /po/BD.
4.T.WYSOLONE 20MG /PO/OD.
5.INJ. HAI S/C PRE MEAL
8AM - 2PM - 8PM
6.Wt and Abd girth- daily
7.strict I/O charting.
8.BP/PR/TEMP 4TH HRLY.
9. GRBS - 7 o PROFILE
8AM -10AM
2PM-4PM
8PM-10PM
10. TAB . RIFAMIXIN 550MG /PO/BD.
2PM-3PM-4PM
29/10/21;
SOAP NOTES DAY 5
AMC BED 5
Case seen by :
Dr.Sai Surya(intern )
Dr.Neha (intern )
Dr.Trishaala(intern )
Dr.Varaprasad(intern )
Dr.Srivalli(intern )
Dr.Harika.K (intern )
Dr.Aashitha PG Y 3
Dr.Nikitha PG Y3
Dr.Usha PG Y 3
Dr.Shashikala PG Y3
Dr.Hareen Sr Resident
Dr.Arjun kumar Ass prof
Dr .Rakesh Biswas HOD
S:
no fresh complaints.
O:
Pt is C/C/C
Afebrile
BP: 110/70mmhg
PR:86bpm regular,normal volume
RR:18CPM
CVS: S1S2 +, no murmers.
RS: NVBS + ,no crepts.
P/A: Distended
SHIFTING DULLNESS+
B.S +
GRBS: 237MG%
I/O: 700/1050ML
SPO2: 98% @RA
SPLENOMEGALY+
DIDNT PASS STOOLS
NO ENGORGED VEINS
WEIGHT: 34KGS
ABD GIRTH-72cms
A:
CLD secondary to CIRRHOSIS
-with K/C/O TYPE 1 DM with
UNCONTROLLED SUGARS.
- with H/O ? APLA.
-? SUB CLINICAL HYPOTHYROIDISM
P:
1.Fluid restriction<1.5 lit/day
2.salt restriction: <2gm/day
3.T.LASILACTONE 20/50mg /po/BD.
4.T.WYSOLONE 20MG /PO/OD.
5.INJ. HAI S/C PRE MEAL
8AM NPH - HAI - NPH
15 - NPH - 15
10- 10 - 10} HAI
6.TAB.RIFAXIMIN 550MG /PO/BD
7.Wt and Abd girth- daily
8.strict I/O charting.
9.BP/PR/TEMP charting.
10.GRBS 7 0 PROFILE MONITORING
8AM - 2PM - 8PM - 2AM
10AM 4PM 10PM
30/10/21;
SOAP NOTES DAY 6
SHIFTED TO WARD.
Case seen by :
Dr.Sai Surya(intern )
Dr.Neha (intern )
Dr.Trishaala(intern )
Dr.Varaprasad(intern )
Dr.Srivalli(intern )
Dr.Harika.K (intern )
Dr.Aashitha PG Y 3
Dr.Nikitha PG Y3
Dr.Usha PG Y 3
Dr.Shashikala PG Y3
Dr.Hareen Sr Resident
Dr.Arjun kumar Ass prof
Dr .Rakesh Biswas HOD
S:
NO FRESH COMPLAINTS.
O:
Pt is C/C/C
Afebrile
BP: 110/70mmhg
PR:82bpm regular,normal volume
RR:16CPM
CVS: S1S2 +, no murmers.
RS: NVBS + ,no crepts.
P/A: Distended
SHIFTING DULLNESS+
B.S +
GRBS: 258MG%
I/O: 600/1250ML
SPO2: 98% @RA
SPLENOMEGALY+
PASSED STOOLS
NO ENGORGED VEINS
WEIGHT: 34.6KGS
ABD GIRTH-70cms
A:
CLD secondary to CIRRHOSIS
-with K/C/O TYPE 1 DM with
UNCONTROLLED SUGARS.
- with H/O ? APLA.
-? SUB CLINICAL HYPOTHYROIDISM
P:
1.Fluid restriction<1.5 lit/day
2.salt restriction: <2gm/day
3.T.LASILACTONE 20/50mg /po/BD.
4.T.WYSOLONE 5MG /PO/OD.
5.INJ. HAI S/C PRE MEAL
8AM NPH - HAI - NPH
15. 12. 15
12. 12
6.TAB.RIFAXIMIN 550MG /PO/BD
7.Wt and Abd girth- daily
8.strict I/O charting.
9.BP/PR/TEMP/GRBS charting.
She got discharged on 30/10/21 @ 2:30 pm
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