Gen med case presentation;
Feb 7,2022
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:05/02/22
chief compliants: A 65 yr old female ,Home maker came to the casuality on 5/02/22 with complaints of altered sensorium since 2 hrs .
She was apparently asymptomatic 3 yrs back
3 yrs back due to back pai and B/L knee pain pt used NSAIDS and herbal medication for pain relief.(intermittent use)
45 days back she had thorn injury in left leg for which she went to local hospital for non healing status of injury ,there she diagnosed with DM and HTN ( on medication )
4 days back she went for regular checkup where her creatinine levels were found to be high.
Now she c/o altered sensorium since 2 hrs,sob at rest since 1 day and also vomitings and decreased urine output .
Personal history;
Diet :mixed
Appetite; normal
Bladder; reduced output
Sleep : adequate
No addictions
General examination;
She is c/c/c
Pallor - present
Icterus, clubbing, lymphadenopathy- absent
Oedema - present
Vitals ;
Temp; afebrile
PR;90bpm
BP;200/120 mm hg
RR;22 cpm
SPO2; 99.6 at RA
Systemic examination;
RS: BAE+
CVS ; S1 ,S2 HEARD
CNS ; NAD
Investigations;
CBP;
Hb- 9.0
TLC-7800
PLATELETS-1.73
RBC-NC,NC
RFT;
Urea;139
Creatinine;5.7
Na+;137
K+;5.1
Cl;102
Serology - negative
LFT;
TB;0.45
DB;0.16
AST;38
ALT;27
ALP;210
TP;5.4
A/G RATIO;1.36
Albumin;3.11
USG;
2D ECHO ;
ECG;
Provisional diagnosis;
Hypoglycemia secondary to OHA,
?DIABETIC NEPHROPATHY
? NSAID INDUCED NEPHROPATHY
Treatment;
On 5/2/22:
Inj.10 D infusion to maintain Grbs 150-200 mg/dl
Hourly Grbs monitoring
Inj.lasix 40mg iv/bd
Inj.pan 40 mg iv/OD
Inj.optineuron 1 amp in 100 ml NS iv/OD
On 6/2/22:
GRBS monitoring hourly
Inj.10 D infusion
Inj.lasix 40 mg iv/ bd
Tab.Amlong 10 mg po/OD
Inj.pan 40 mg iv/oD
Inj optineuron 1 amp in 100 ml NS iv/ OD
On 7/2/22 :
GRBS monitoring 2 hourly
Inj.pan 40 mg iv/OD
Inj.optinueron 1 amp in 100 ml NS IV/OD
Tab. Amlong 10 mg po/OD
Tab .nicardia 20 mg po/ TID
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