A 50 year old woman presented with nausea

Hi, I am princy rose , 5 th sem medical student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

June 6,2023

Case scenario.......

CASE SHEET:

A 50 yr old female patient , who is a housewife came to the OPD with complaints  nausea.

Date of admission: 03/06/2023

CHIEF COMPLAINTS 

➤ Nausea since 5 days 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 1 month back . Then she developed edema in both U/L and L/L , facial puffiness, distension of abdomen. 

She was taken to a local practitioner in Nalgonda and diagnosed with Blood Infection ? B/L pneumonia? and was treated conservatively ( Lasik, Lasilactone, Augmentin ) . The symptoms subsided after 10 days . 

She had burning micturition 10 days ago , associated with itching. 

Then she had decreased appetite and reduced food intake since then . She has complaints of odynophagia  and difficulty in swallowing. 

She has complaints of nausea  since 1 week , associated with one episode of vomitting later . It was non projectile , non bilious , non blood tinged , watery . 

She has 3 episodes of stools/day which is non sticky , foul smelling , yellow coloured , less in quantity, not associated with bleeding .

HISTORY OF PAST ILLNESS 

➤k/c/o hypertension since 15yrs .

➤Not a K/c/o diabetes mellitus, asthma , epilepsy tuberculosis , CAD. 

DRUG HISTORY 

Tab. Met XL 25mg PO /OD for Hypertension for last 15yrs .

PERSONAL HISTORY

➤Occupation: Housewife 

➤Patient is married .

➤Patient takes mixed diet but has a decreased appetite 

➤Bowel and bladder movements are normal 

➤No known allergies .

➤ H/O analgesic abuse since 1 yr (prescribed 

for Osteoarthritis) 

➤ No addictions. 

Family History 

Mother died of blood cancer . 

Brother died of heart attack. 

General Examination

➤Pallor : seen 

➤Icterus : not seen 

➤Cyanosis : not seen 

➤Clubbing : not seen 

➤Lymphadenopathy : not seen 

➤Edema : B/L edema in both U/L and L/L . 

VITALS 

➤Temperature : 99℉

➤PR : 106 beats per minutes 

➤BP : 100/60 mm of Hg

➤RR : 24 cycles per minute

➤SpO2 : 97% in room air

➤Blood Sugar (random) : 262 mg/dl

PROVISIONAL DIAGNOSIS : DIABETIC KETOACIDOSIS . 

2° to Acute gastroenteritis

Denovo Diabetes mellitus 

INVESTIGATIONS

ECG

Test for Ketone bodies 

Complete urine examination

RFT

Test for Serum protein

USG

Output and input charts

TREATMENT

1) Inj. Human Actrapid Insulin 6U/IV/stat 

2) Inj. Human Actrapid Insulin 1ml+39ml/NS at 6ml/hr .

3) IVF NS at 100ml/hr (increase/decrease according to GRBS) 

4) Monitoring of GRBS, BP , RR , temp 

5) Strict I/O charting .

6) Repeat ABG at 2pm/8am