22 year old female with complaints of nausea , decreased appetite and pain in the epigastric region since 4 days


































DR. YAMINI ( INTERN) 
DR. AMULYA ( INTERN) 
DR. SURYA PRADEEP ( INTERN) 
DR. ASHA KIRAN ( INTERN) 
DR. JAYANTH ( INTERN) 
DR. VAMSHI ( INTERN) 
DR. PRADEEP ( PG 1st YEAR)
DR. CHANDANA ( PG 1st YEAR) 
DR. USHA ( PG 2nd YEAR) 
DR. SUFIYA ( PG 3rd YEAR) 
DR. SATISH ( PG 3rd YEAR) 
Faculty : DR. VIJAYALAXMI ( Asst. Prof.)
DR. RAKESH BISWAS HOD




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 patient's 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 the comment box is welcome.


Here is a case i have seen:
Admission under unit 2 on 26/01/2021(Day-0)
A 22 year old female who is a housewife resident of vemulapally  mandal came to casualty with a chief complaint of nausea since 4 days , decreased appetite since 4 days and pain in the epigastric region since 4 days. 
HOPI: patient was apparently asymptomatic 4 days back later she had c/o nausea since 4 days , decreased appetite since 4 days, intake of food followed by vomitings , pain abdomen at epigastric region since 4 days. 
C/o bilateral swelling of lower limbs up to ankle since 4 days which is pitting type , c/o constipation since 4 days . No h/o Fever , cough, cold, burning micturition .
normal urine output .
H/o similar complaints 15 days back (admitted in outside hospital for 2 days). 
Pt is a k/c/o type 1 DM diagnosed at the age of 12 years when admitted in hospital ( kamineni hospitals) for fever and is on insulin therapy ( mixtard). 
Not a k/c/o HTN, Asthma , TB, CAD and no h/o blood transfusions 
Personal history: she is a vegetarian and with h/o decreased appetite 
No known allergies 
No addictions.
Menstrual history : she attained menarche at the age of 12 years with regular cycles of 3/28, no dysmenorrhea LMP: 2 days back
General examination: 
Patient is conscious , coherent , cooperative oriented to time, place, person 
Pallor is present , no signs of icterus, cyanosis, clubbing 
B/L pedal edema pitting  type present up to ankles 
Signs of malnutrition and dehydration present 
Vitals: temp: 97OF 
PR : 120bpm regular rhythm normal volume 
RR : 16cpm 
BP: 200/120 mm of hg 
SpO2 : 98% on RA 
GRBS: 534 mg/dl 





Systemic examination: 
CVS: S1 S2 heard , no murmurs 
RS : NVBS heard , no added sounds 
CNS: no focal deficits 
P/A : soft , tenderness present in epigastric region , bowel sounds heard. 
           PROVISIONAL DIAGNOSIS: 
Diabetic ketoacidosis with ? Hypertensive urgency  with k/c/o DM type 1 with anaemia( microcytic hypochromic) under evaluation. 
 INVESTIGATIONS: 











 










Treatment 
  1. NBM till further orders 
  2. Inj. HAI 40 units in 49ml of NS/ IV @6ml/ hour 
  3. Inj. PANTOP 40mg / IV/ OD 
  4. Inj. ZOFER 4mg/ IV / TID 
  5. TAB. NICARDIA 10mg/ PO/ Stat 
  6. IVF NS @ 50ml/ hour 
  7. Tab. TELMA 20mg/ PO/ OD
  8. Strict I/O charting 
  9. BP charting 2nd hourly 
  10. GRBS charting 1 hourly 
  11. Temp/ PR/ BP/ spo2 charting 4th hourly 

DAY-2 (28-1-2021)

Patient complaining of swelling around eyes and watering from the eyes since yesterday afternoon. No fever spikes overnight. 
Patient is feeling hungry. Patient didn’t pass stools but passing flatus. 
Examination: 
Patient is conscious, coherent, cooperative 
B/L pedal edema pitting type present upto midcalf 
Raised JVP 
Vitals: 
Temp : afebrile to touch 
BP: 150/100 mm of hg 
PR: 94bpm normal volume, regular rhythm 
SpO2: 98% on RA 
RS: BAE + 
CVS: S1S2 heard 
CNS: no focal deficits 
P/A : soft non tender BS+ 

INVESTIGATIONS: 








PROVISIONAL DIAGNOSIS: 
DIABETIC KETOACIDOSIS ( RESOLVED) 
WITH HYPERTENSIVE URGENCY( DENOVO) 
WITH CHOLELITHIASIS WITH HYPOPROLIFERATIVE ANEMIA (?IRON DEFICIENCY) SECONDARY TO NUTRITIONAL WITH K/C/O TYPE 1 DM WITH HTN AND DIABETIC RETINOPATHY CHANGES ? DIABETIC NEPHROPATHY. 

TREATMENT: 
Rx: 
  1.  Salt restricted diet ( <2.4g/day)
  2. Strict diabetic diet 
  3. Day 2 TAB. CEFIXIME 200 mg/PO/ BD
  4. TAB. ONDEN 4mg  /PO/ SOS 
  5. TAB. TELMA-H 40mg/ PO/ OD 
  6. TAB. ALDACTONE 50mg/ PO/ BD 
  7. Inj. HAI /SC/TID 
  8. Syp. CITRALKA 10ml in 1 glass of water /PO/ TID 
  9. TAB. PCM 650mg / PO/ SOS
  10. Syp. CREMAFFIN 15ml / PO/ BD
  11. GRBS charting 6th hourly 
  12. BP/ PR/ SpO2/ Temp charting 4th hourly 
  13. Strict I/O charting

DAY-3 (29-1-2021)

S - complaints of peri orbital puffiness left eye(Due to depended part sleeping over night)

O -  patient is c/c/c
     BP - 160/100mm hg
     PR - 122 BPM
     Spo2- 98% on RA
     CVS -  S1 S2 heard, no murmurs
     RS - BAE present
     CNS - no focal deficit

A - DKA (resolved), denovo hypertension,Type-1DM with mild daibetic & Hypertensive changes

P - 
1. Salt restricted diet 
2. Strict diabetic diet 
3. TAB. CEFIXIME 200mg/PO/BD
4. TAB. ONDEN 4mg/PO/ SOS
5. TAB. TELMA- H (40/12.5mg) /PO/BD
6. Inj. HAI/SC/ TID 
7. Syp.CITRALKA 10ml in 1 glass of water / PO/ TID 
8. Syp. CREMAFFIN 15ml/PO/TID
9, GRBS charting 6th hourly 
10. BP/PR/ SPO2 /Temp charting 4th hourly 
11. TAB. ATORVASTATIN 10mg/ PO/ HS 
12. Eye drops LUBREX / QID
13. Inj. LASIX / IV/ TID 


INVESTIGATIONS: 



DAY- 4 (30-1-2021)
S -  4 episodes of vomitings yesterday night, where the first episodes content was food she had eaten and then it was only water . Complaining of retrosternal burning sensation.

O -  patient is conscious , coherent and cooperative. Peri orbital puffiness subsided significantly.
     BP - 160/110mm hg
     PR - 136 BPM
     Spo2- 98% on RA
     CVS -  S1 S2 heard, no murmurs
     RS - BAE present
     CNS - no focal deficit

A - DKA (resolved), denovo hypertension,?Glomerulo nephritis

P - 
1. Salt restricted diet 
2. Strict diabetic diet 
3. Inj. LASIX /IV/ BD 
4. Inj. ONDEN 4mg/IV/ TID 
5. Tab. TELMA-H (40/12.5mg) /PO/ BD 
6. Inj. INSULIN S/C     
               BBF.  BL.  BD
Reg.        5.      5.     5 
NPH.       8.      -       7 
7. Tab. ATORVASTATIN 10mg/ PO/HS 
8. Syp. CREMAFFIN 15ml/ PO/ BD
9. LUBREX eye drops / QID 
10. GRBS charting 6th hourly 
11. Strict i/o charting 
12. BP/PR/ RR/ SpO2 / temp charting 6th hourly 
13. Tab. CEFIXIME 200mg / PO/ BD 
14. Inj. PAN 80mg in 50ml NS over 2 hours 
INVESTIGATIONS: 
  
DAY-5 (31-01-2021)
S -  2-3 episodes of vomitings yesterday night, where content was food she had eaten and Complaining of retrosternal burning sensation , neck pain present 

O -  patient is conscious , coherent and cooperative. Peri orbital puffiness subsided significantly. 
     BP - 140/100 mm hg
     PR - 117BPM
     Spo2- 98% on RA
     CVS -  S1 S2 heard, no murmurs
     RS - BAE present
     CNS - no focal deficit

A - DKA (resolved), denovo hypertension,?Glomerulo nephritis

P - conservative treatment

INVESTIGATIONS: 


DAY- 6 (1-02-2021)
S-5Episodes of vomitings yesturday evening,Neck pain(Relieved Today)

O-Pt is c/c/c 
Bp-140/100 mmhg
PR-130/min
Spo2-98% on room air
Cvs-S1 S2 heard,No murmurss
RS-BAE +
CNS-No focal deficit

A-DKA(Resolved),Hypertensive Urgency(Resolved),Denovo HTN,Diabetic Nephropathy(Stage-3)
     
P-Conservative
INVESTIGATIONS: 


 

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