5th May 2022
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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 a diagnosis and treatment plan.
18 year old male residing at Mungodu (nalgonda) came with c/o
- weight loss and unable to gain weight since 1year
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 1 year back and his sister noticed that he started loosing weight approximately 5-8kg in a duration of a year and not able to gain weight in spite of taking food regularly.
- c/o increased appetite (polyphagia 6-8 meals per day) since 1 year
- c/o polyuria (2-3 times overnight)
- No h/o fever, cough, cold
- No h/o bleeding manifestations, dark coloured stools
- No h/o palpitations, sob, pedal edema
His parents both are stone cutters since his childhood. He used to go along with their parents and used to help them.
PAST HISTORY :
- H/O ? Febrile seizures @ 2 years
- No h/o similar complaints in the past
- No h/o DM, HTN, TB, asthma
FAMILY HISTORY :
No h/o DM, HTN, TB, asthma and epilepsy
BIRTH HISTORY :
Full term normal vaginal delivery
H/o consanguinity +
DEVELOPMENTAL HISTORY :
Delayed milestones
Walking at the age of 3 years
PERSONAL HISTORY :
Diet - mixed
Appetite - increased
Sleep - adequate
Bowel and bladder movements - regular
DIETARY HISTORY :
- Early morning - glass of tea
- Morning for breakfast - rice + cup of curry
- Lunch - rice 2-3 cups + 2 cups of curry
- Dinner - rice 2-3 cups + 2 cups of curry
- In between these meals he also consumes same amount of food with 1-2 cups of curry every 2-3 hrly
- He consumes routinely dal(mostly) also leaf curries, brinjal etc
- He doesn't consume eggs as he don't like them
- Meat ( chicken 1 cup) once in a while of 1-2 months
GENERAL EXAMINATION :
- Patient is conscious, coherent
- No pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema
VITALS :
Temp - 98.3 F
PR - 98 bpm
RR - 18 cpm
BP - 100/80 mm Hg
Spo2 - 98% @ room air
GRBS - >450 mg/dl
SYSTEMIC EXAMINATION :
CVS - S1S2 +
RS - BAE+
P/A - soft, nontender
CNS - NAD
Higher motor functions - intact
INVESTIGATIONS :
RBS :
ABG :
URINE FOR KETONE BODIES :
ECG :
USG ABDOMEN AND PELVIS :
BLOOD UREA :
LIVER FUNCTION TEST (LFT) :
SERUM CREATININE :
SERUM ELECTROLYTES :
HEMOGRAM :
CUE :
THYROID PROFILE:
CHEST X RAY PA VIEW :
SEROLOGY : NEGATIVE
DIAGNOSIS : UNCONTROLLED SUGARS WITH DENOVO DETECTED TYPE 1 DIABETES MELLITUS
ENDOCRINOLOGY REFERRAL :
OPHTHALMOLOGY REFERRAL :
GRBS CHARTING :
PLAN OF CARE :
1. IVF - NS, RL @ 100ML/HR
2. INJ HAI ACC. INFUSION CHARTING
3. HOURLY GRBS CHARTING
4. INJ HAI 6U IV/STAT ACCORDING TO SLIDING SCALE
5. INJ ZOFER 4MG IV SOS
6. STRICT I/O CHARTING
7/5/2022
SOAP NOTES DAY 2
S :
- c/o left tooth pain since 1week
- No fever spikes
O :
Patient is conscious
Vitals :
Temp - 98.4f
BP - 100/60mm hg
RR - 20cpm
PR - 78bpm
CVS - s1s2+
RS - BAE +
P/A - soft, nontender
CNS - NAD
INVESTIGATIONS :
6/5/2022 -
SERUM ELECTROLYTES : Na-140, K-3.5, Cl-101
THYROID PROFILE : T3-0.61, T4-6.68, TSH-2.90
7/5/2022 -
HEMOGRAM : Hb-12.7, TLC-5900, N/L/E/M/B-63/28/03/06/00, RBC-4.94, PLATELETS - 2.88
SERUM ELECTROLYTES : Na-139, K-3.9, Cl-99
GRBS TRENDS :
6/5/2022
9am - 251 mg/dL (15U HAI)
11am - 320 mg/dL
1pm - 218 mg/dL (15U HAI)
3pm - 233 mg/dl
7pm - 313 mg/dL (10U HAI + 10U NPH)
9pm - 387 mg/dl
11pm - 406 mg/dl
2am - 80 mg/dl
4am - 140 mg/dl
8am - 116 mg/dL (10U HAI + 8U NPH)
A :
UNCONTROLLED SUGARS WITH DENOVO DETECTED ? TYPE 1 DM
? MALNUTRITION RELATED DIABETES MELLITUS
P :
1. NORMAL ORAL DIET
2. INJ HUMAN ACTRAPID AND NPH ACCORDING TO SLIDING SCALE
3. INJ ZOFER 4MG IV SOS
4. PROTEINEX POWDER 2TSP IN 1GLASS OF MILK
5. SYP POTCHLOR 10ML IN 1GLASS OF WATER TID
6. GRBS MONITORING ACCORDING TO 7-PROFILE
8/5/2022
SOAP NOTES DAY 3
S :
- No fever spikes
O :
Patient is conscious
Vitals :
Temp - 98.2f
BP - 100/70mm hg
RR - 20cpm
PR - 82bpm
CVS - s1s2+
RS - BAE +
P/A - soft, nontender
CNS - NAD
GRBS TRENDS :
7/5/2022
9am - 116 mg/dL (10U HAI + 8U NPH)
11am - 269 mg/dL
1pm - 340 mg/dL (18U HAI)
3pm - 288 mg/dl
8pm - 113 mg/dL (14U HAI + 8U NPH)
10pm - 70 mg/dL (DNS)
12am - 56 mg/dl (25-D)
1am - 195 mg/dl
4am - 325 mg/dl
8am - 245 mg/dL (12U HAI + 8U NPH)
A :
UNCONTROLLED SUGARS WITH DENOVO DETECTED ? TYPE 1 DM
P :
1. NORMAL ORAL DIET
2. INJ HUMAN ACTRAPID AND NPH ACCORDING TO SLIDING SCALE
3. INJ ZOFER 4MG IV SOS
4. PROTEINEX POWDER 2TSP IN 1GLASS OF Milk BD
5. GRBS MONITORING ACCORDING TO 7-PROFILE
9/5/2022
SOAP NOTES DAY 4
S :
- No fever spikes
O :
Patient is conscious
Vitals :
Temp - 98.2f
BP - 100/70mm hg
RR - 18cpm
PR - 76bpm
CVS - s1s2+
RS - BAE +
P/A - soft, nontender
CNS - NAD
GRBS TRENDS :
8/5/2022
8am - 245 mg/dL (12U HAI + 8U NPH)
10am - 148 mg/dL
2pm - 130 mg/dL (10U HAI)
4pm - 48 mg/dl
8pm - 185 mg/dL (8U HAI + 6U NPH)
10pm - 281 mg/dL
2am - 64 mg/dl
8am - 199 mg/dL (10U HAI + 8U NPH)
A :
UNCONTROLLED SUGARS WITH DENOVO DETECTED ? TYPE 1 DM
P :
1. NORMAL ORAL DIET
2. INJ HUMAN ACTRAPID AND NPH
8AM - 6U HAI + 4U NPH
2PM - 6U HAI
8PM - 6U HAI + 4U NPH
3. INJ ZOFER 4MG IV SOS
4. PROTEINEX POWDER 2TSP IN 1GLASS OF Milk BD
5. GRBS MONITORING ACCORDING TO 7-PROFILE
