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.
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
PATIENT CAME TO CASUALITY WITH C/O
B/L PEDAL DEMA - 20 DAYS
FACIAL PUFFINESS - 20 DAYS
BREATHLESSNESS - 1 DAY
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 10 YEARS BACK THEN WAS DIAGNOSED WITH DM-1 AND IS ON INSULIN MITARD (20U-X-16U).SHE HAD 2 EPISODES OF WEAKNESS, UNCONTROLLED SUGARS FOR WHICH SHE WAS ADMITTED FOR A DAY &DISCHARGED ( 1ST EPISODE 5YEARS BACK AND 2ND EPISODE 3 YEARS BACK RESPECTIVELY).ON NOV
2022 PATIENT WAS TAKEN TO GOVT HOSPITAL I/v/O SOB AND WAS DIAGNOSED WITH DENOVO HYPERTENSION, UNCONTROLLED SUGARS ( STARTED ON ? HTN MEDICATION).ON 2ND JAN 2023, SHE HAD EPISODES OF VOMITINGS, LOOSE STOOLS AND WAS ADMITTED IN AIIMS & WAS DIAGNOSED WITH PANCYTOPENIA ,DIABETIC NEPHROPATHY, DILATED CARDIOMYOPATHY,HTN ,VIT D DEFICIENCY RIGHT EYE PSEDUOPHAKIA AND LEFT EYE IMSC WITH HYPERPIGMENTED LESION ON RIGHT FOOT (?
CALLOSITY).6 DAYS BACK SHE DEVELOPED PEDAL EDEMA AND SOB WHICH WAS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE (GRADE 2 TO 4) ASSOCIATED WITH ORTHOPNOEA AND WAS BROUGHT TO OUR HOSPITAL AS HER SYMPTOMS DIDN'T SUBSIDE.
PAST HISTORY:
K/C/O DM TYPE 1 SINCE 10 YEARS AND IS ON INSULIN
K/C/O HTN FROM 2 MONTHS AND ON T TELMA+CLINIDIPINE AND T METXL
H/O OF RIGHT EYE CATARACT SURGERY: 8 YEARS BACK
PERSONAL HISTORY:
APPETITE - NORMAL
DIET - MIXED
BOWEL AND BLADDER - REGULAR
SLEEP - ADEQUATE
GENERAL EXAMINATION:
PT IS C/C/C
PALLOR: PRESENT
PEDAL EDEMA - PRESENT,PITTING TYPE, TILL KNEE NO ICTERUS,CYANOSIS,CLUBBING,
LYMPHADENOPATHY
VITALS ON ADMISSION:
PR-113 BPM
BP- 220/120MM HG
RR- 26 CPM
SPO2- 72% AT RA
GRBS - HIGH
SYSTEMIC EXAMINATION:
1) PER ABDOMEN:
INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.
PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.
ASCULTATION: BOWEL SOUNDS - HEARD
2)RESPIRATORY SYSTEM:
INSPECTION: SHAPE OF THE CHEST IS ELLIPTICAL. B/L SYMMETRICAL. BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.
PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL VOCAL FREMITUS IS NORMAL
PERCUSSION: RESONANT BIL
ASCULTATION: BAE + , NVBS HEARD
3) CVS:
INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.
PALPATION: APEX BEAT FELT IN LEFT 5TH ICS. NO THRILLS AND PARASTERNAL HEAVES.
ASCULTATION: S1S2 +,NO MURMURS
4) CNS:
PATIENT WAS C/C/C.
HIGHER MENTAL FUNCTIONS- INTACT
GCS - E4V5M6
B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT
NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEM-NORMAL,
MOTOR SYSTEM: TONE- NORMAL, POWER- 5/5 IN ALL LIMBS REFLEXES: BICEPS - 2+, TRICEPS-2+, SUPINATOR + , KNEE - 2+, ANKLE - 2+
Diagnosis:
TYPE 1 DM WITH UNCONTROLLED SUGARS (RESOLVING)
WITH HYPERTENSIVE EMERGENCY (RESOLVED)
?NEPHROTIC SYNDROME
WITH HFpEF (EF:66%)
BICYTOPENIA SECONDARY TO B12 DEFICIENCY
ANEMIA OF CHRONIC DISEASE
HEPATIC HEMANGIOMA
HTN SINCE 2 MONTHS &DM SINCE 20 YEARS NON PROLIFERATIVE DIABETIC RETINOPATHY]
Treatment:
1.IVF NS @ 30 ML/HR
2.STRICT DIABETIC DIET
3.INJ LASIX 40 MG IV BD
4.T TELMA 40 MG PO BD
5.T CLINIDIPINE 10 MG PO BD
6.T METXL 25 MG PO OD
7.T DYTOR PLUS PO OD
8.T NICARDIA 20 MG PO BD
9.INJ HAI ACCORDING TO GRBS
10.INJ GLARGINE 10 U @ 10 PM
11.T THYRONORM 25 MCG PO OD
BRIEF COURSE IN HOSPITAL: (6/2/23) PATIENT WAS BROUGHT TO THE HOSPITAL WITH ABOVE COMPLAINTS AND NECESSARY INVESTIGATIONS WERE DONE, HER SUGARS WERE FOUND TO BE HIGH AND BP BEING 220/110MMHG ON PRESENTATION AND WAS TREATED SYMPTOMATICALLY. REFRRALS WERE TAKEN FROM ENDOCRINOLOGIST I//O HIGH SUGARS,NEPHROLOGIST I/V/O HIGH CREATININE AND OPTHALMOLOGIST INIO DIABETIC &HYPERTENSIVE RETINOPATHY CHANGES.INITIALLY FOR HYPERTENSION,SHE WAS TREATED WITH T. TELMA 40MG + CLORTHALIDONE 12.5MG AND T.METXL 25MG AND LATER ON WAS FIXED ON T.NICARDIA 20MG PO/BD(8AM-X-8PM) AND ON ADVISE OF NEPHROLOGIST INJ ERYTHROPOIETIN 2000 UNITS S/C WAS GIVEN. THYRONORM 25MCG WAS STARTED I//O HYPOTHYROIDISM ON 4/2/23 AND PATIENT WAS DISCHARGED UNDER HEMODYNAMICALLY STABLE CONDITION.
Patient has been in constant touch with our doctor’s via PAJR group
Here’s the conversation from today(19/2/23)
Ragi mudda na ??
With jaggery...
That's too much sugar! Please avoid Jaggery 😳
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