MEDICINE CASE DISCUSSION
This is an 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 centered online learning portfolio and your valuable inputs on comment box is welcome.
CASE SCENARIO:
A 50 year old female came to the casualty in hypoactive state. On presentation Patient was conscious with small quantity of froth from mouth and uprolling of eyes present. Vitals were stable, GRBS -42 mg/ dl, immediate 25% dextrose transfusion was done and sensorium improved.
— 2D echo
After 25% dextrose transfusion, her GRBS was 150mg/dl.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 month back, then she developed blebs (? necrotic patch) on her right toe. She went to a local hospital where dressing was done and she was advised amputation.
Patient had history of trauma to right toe.
On examination:
necrotic patch over RT toe
pus discharge present
foul smelling
movements reduced
Surrounding skin- dark/black pigmentation extending till the middle of foot.
No sensations present over the toe
Local rise of temperature present
Peripheral pulses felt
Outside reports (4/9/21):
Hb: 6.8 g/dl
WBC: 16,500
PLT count: 5,84,000
PAST HISTORY:
k/c/o Type 2 Diabetis Mellitus and Hypertension since 10 years.
PERSONAL HISTORY:
Diet: mixed
Appetite: lost
Irregular bowel and bladder movements
No addictions
Menstrual history: post menopausal
GENERAL EXAMINATION:
Pallor +
No icterus, clubbing, cyanosis, lymphadenopathy, pedal edema
VITALS:
Temp: afebrile
BP: 120/80 mm Hg
PR: 98 BPM
RR: 14 cpm
SpO2: 98%
GRBS: 42 mg/dl
SYSTEMIC EXAMINATION:
CVS :
S1S2 HEARD
no thrills no murmurs
P/A:
Soft, non tender
Non distended
Guarding and rigidity absent
RS: BAE+
CNS:
Patient is Conscious
Speech: normal
No signs of Meningeal irritation
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
INVESTIGATIONS:
— ECG
— USG Abdomen
— Artierial and Venous DOPPLER
— Chest XRay
— Right Foot XRay
— Hemogram
— RFT
— LFT
— ABG
5/9 1:25 AM
5/9 7:15 AM
6/9 7 AM
— urine Na : 144 mmol/L
urine K : 10.5
urine Cl : 172 mmol/L
— Spot urine protein: 47 mg/dl
Spot urine creatinine: 29.9 mg/dl
P/C ratio : 1.57
— Blood group and Rh typing: O+ve
— APTT : 33 sec
Prothrombin time : 16 sec
INR : 1.11
— FBS: 45 mg/dl
RBS: 75 mg/dl
— Blood urea: 273 mg/dl
Serum creatinine: 9 mg/dl
— Serum electrolytes
PROVISIONAL DIAGNOSIS:
AKI ON CKD
DIABETIC FOOT
WITH K/C/O DM TYPE 2 AND HTN SINCE 10 YEARS
SOAP NOTES:
DAY ZERO
Subjective:
Hypoactive state
After 25% D, sensorium improved
3 episodes of vomitings
Wound to right toe
Objective:
pt is c/c/c
GRBS: 42 mg/dl
Temp: afebrile
BP: 90/60 mm Hg
PR: 80/min
CVS: s1, s2 heard
RS: BAE +
CNS: NAD
P/A: soft, non tender
Assessment:
AKI on CKD
Diabetic foot
with k/c/o DM - II and HTN since 10 yrs
Treatment:
1) IVF NS, RL @ 100ml/hr.
2) INJ. PIPTAZ 4.5gm IV/STAT
|
2.25 gm IV/TID
3) INJ PANTOP 40 mg IV/OD
4) INJ ZOFER 4 mg IV/TID
5) INJ LAXIX 40 mg IV/BD
8 am - - 4 pm - - x (if SBP > 110 mm Hg)
6) INJ HAI S/C
8 am - - 2 pm - - 8 pm
7) INJ METROGYL 400 mg IV/BD
8) GRBS- to profile
9) I/O charting
10) BP/PP/TEMP/PR- 4th Hrly
DAY ONE
Subjective:
2 episodes of vomitings
Appetite decreased
Objective:
pt is c/c/c
GRBS: 256 mg/dl
Temp: afebrile
BP: 120/70 mm Hg
PR: 88/min
CVS: s1, s2 heard
RS: BAE +
CNS: NAD
P/A: soft, non tender
Assessment:
AKI on CKD
Diabetic foot
with k/c/o DM - II and HTN since 10 yrs
Treatment:
1) IVF NS @ 100 ml/hr.
2) INJ. PIPTAZ 2.25 gm IV/TID
3) INJ. ZOFER 4 mg IV/TID
4) INJ. LASIX 40 mg IV/BD
5) INJ. METROGYL 400 mg IV/TID
6) INJ. PANTOP 40 mg IV/OD
7) INJ. HAI acc to sliding scale
8) Inform GRBS
9) GRBS- 6th hrly
10) I/O charting
11) Monitor vitals: 4th hrly
DAY TWO
Subjective:
No episodes of vomitings
Appetite improved
Objective:
pt is c/c/c
GRBS: 127 mg/dl
Temp: afebrile
BP: 120/70 mm Hg
PR: 90/min
CVS: s1, s2 heard
RS: BAE +
CNS: NAD
P/A: soft, non tender
Assessment:
AKI on CKD
Diabetic foot
with k/c/o DM - II and HTN since 10 yrs
Treatment:
1) IVF NS @ 100 ml/hr.
2) INJ. PIPTAZ 2.25 gm IV/TID
3) INJ. ZOFER 4 mg IV/TID
4) INJ. LASIX 40 mg IV/BD
5) INJ. METROGYL 400 mg IV/TID
6) INJ. PANTOP 40 mg IV/OD
7) INJ. HAI acc to sliding scale
8) Inform GRBS
9) GRBS- 6th hrly
10) I/O charting
11) Monitor vitals: 4th hrly
DAY THREE
Subjective:
No episodes of vomitings
Mild headache +
Appetite improved
Objective:
pt is c/c/c
GRBS: 130 mg/dl
Temp: afebrile
BP: 130/80 mm Hg
PR: 86/min
CVS: s1, s2 heard
RS: BAE +
CNS: NAD
P/A: soft, non tender
Assessment:
AKI on CKD
Diabetic foot
with k/c/o DM - II and HTN since 10 yrs
Treatment:
1) IVF NS @ 100 ml/hr.
2) INJ. PIPTAZ 2.25 gm IV/TID
3) INJ. ZOFER 4 mg IV/TID
4) INJ. LASIX 40 mg IV/BD
5) INJ. METROGYL 400 mg IV/TID
6) INJ. PANTOP 40 mg IV/OD
7) INJ. HAI acc to sliding scale
8) Inform GRBS
9) GRBS- 6th hrly
10) I/O charting
11) Monitor vitals: 4th hrly
DAY FOUR
Subjective:
No episodes of vomitings
Mild headache +
Objective:
pt is c/c/c
GRBS: mg/dl
Temp: afebrile
BP: 120/70 mm Hg
PR: 90/min
CVS: s1, s2 heard
RS: BAE +
CNS: NAD
P/A: soft, non tender
Assessment:
AKI on CKD
Diabetic foot
with k/c/o DM - II and HTN since 10 yrs
Treatment:
1) IVF NS @ 100 ml/hr.
2) INJ. PIPTAZ 2.25 gm IV/TID
3) INJ. ZOFER 4 mg IV/TID
4) INJ. LASIX 40 mg IV/BD
5) INJ. METROGYL 400 mg IV/TID
6) INJ. PANTOP 40 mg IV/OD
7) INJ. HAI acc to sliding scale
8) Inform GRBS
9) GRBS- 6th hrly
10) I/O charting
11) Monitor vitals: 4th hrly
DAY FIVE
Subjective:
No episodes of vomitings
Headache resolved
Objective:
pt is c/c/c
GRBS: 185 mg/dl
Temp: afebrile
BP: 120/80 mm Hg
PR: 88/min
CVS: s1, s2 heard
RS: BAE +
CNS: NAD
P/A: soft, non tender
Assessment:
AKI on CKD
Diabetic foot
with k/c/o DM - II and HTN since 10 yrs
Treatment:
1) IVF NS @ 100 ml/hr.
2) INJ. ZOFER 4 mg IV/TID
3) INJ. LASIX 40 mg IV/BD
4) INJ. METROGYL 400 mg IV/TID
5) INJ. PANTOP 40 mg IV/OD
6) INJ. HAI acc to sliding scale
7) Inform GRBS
8) GRBS- 6th hrly
9) I/O charting
10) Monitor vitals: 4th hrly
11) INJ. TRAMADOL 1 amp in 100 ml NS IV/slow
DAY SIX:
Subjective:
No episodes of vomitings
No headache
Objective:
pt is c/c/c
GRBS: 276 mg/dl
Temp: afebrile
BP: 110/70 mm Hg
PR: 84/min
CVS: s1, s2 heard
RS: BAE +
CNS: NAD
P/A: soft, non tender
Assessment:
AKI on CKD
Diabetic foot
with k/c/o DM - II and HTN since 10 yrs
Treatment:
1) IVF NS @ 100 ml/hr.
2) INJ. ZOFER 4 mg IV/TID
3) INJ. LASIX 40 mg IV/BD
4) INJ. METROGYL 400 mg IV/TID
5) INJ. PANTOP 40 mg IV/OD
6) INJ. HAI acc to sliding scale
7) Inform GRBS
8) GRBS- 6th hrly
9) I/O charting
10) Monitor vitals: 4th hrly
11) INJ. TRAMADOL 1 amp in 100 ml NS IV/slow
DAY SEVEN:
Subjective:
Pain in right side of head and neck
Objective:
pt is c/c/c
GRBS: 166 mg/dl
Temp: afebrile
BP: 100/60 mm Hg
PR: 70/min
CVS: s1, s2 heard
RS: BAE +
CNS: NAD
P/A: soft, non tender
Assessment:
AKI on CKD
Diabetic foot
with k/c/o DM - II and HTN since 10 yrs
Treatment:
1) IVF NS @ 100 ml/hr.
2) INJ. ZOFER 4 mg IV/TID
3) INJ. LASIX 40 mg IV/BD
4) INJ. METROGYL 400 mg IV/TID
5) INJ. PANTOP 40 mg IV/OD
6) INJ. HAI acc to sliding scale
7) Inform GRBS
8) GRBS- 6th hrly
9) I/O charting
10) Monitor vitals: 4th hrly
11) INJ. TRAMADOL 1 amp in 100 ml NS IV/slow
12) Tab. AMOXICLAV 625 mg PO/BD
DAY EIGHT:
Subjective:
Pain in right side of neck
Objective:
pt is c/c/c
GRBS: 139 mg/dl
Temp: afebrile
BP: 170/80 mm Hg
PR: 72/min
CVS: s1, s2 heard
RS: BAE +
CNS: NAD
P/A: soft, non tender
Assessment:
AKI on CKD
Diabetic foot
with k/c/o DM - II and HTN since 10 yrs
Treatment:
1) IVF NS @ 100 ml/hr.
2) INJ. ZOFER 4 mg IV/TID
3) INJ. LASIX 40 mg IV/BD
4) INJ. TRAMADOL 1 amp in 100 ml NS IV/slow
5) INJ. PANTOP 40 mg IV/OD
6) Tab. AMOXICLAV 625 mg PO/BD
7) INJ. HAI acc to sliding scale
8) Inform GRBS
9) GRBS- 6th hrly
10) I/O charting
11) Monitor vitals: 4th hrly
Comments
Post a Comment