26th 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.
39year old female who is homemaker at present and used to work as Asha worker 10years back came with
- c/o recurrent vomitings immediately after intake of food since 2months (on and off) and aggravated since 2days
- c/o constipation since 1 1/2 year and passes stools once in 4-5 days
- c/o irregular menses since 1 1/2 year
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 15years back, then patient c/o generalised weakness for which they went to hospital and was diagnosed as type 2 DM and was started on OHA's.
In 2017, patient c/o gluteal swelling for which incision and drainage was done and since then she was advised i/v/o uncontrolled sugars ? INJ HUMAN MIXTARD 15U MORNING and 6U NIGHT and OHA's in afternoon. The time for wound healing was 2months.
2years back she had h/o fall due to slipping on floor and had a fracture at the region of right ankle ( ? hairline fracture).
1 1/2year back patient went to hospital wit c/o constipation and irregular menses and was diagnosed with HYPOTHYROIDISM (T3-2.15, T4-1.55, TSH-0.14) and she was started on TAB THYRONORM 100MCG. After 3months she was switched to 25MCG. Constipation was relieved only after taking medication.
Since 2months, she c/o recurrent vomitings - 2episodes/day after taking food, non-bilious, non-blood stained, non foul smelling, food particles as content, aggravated on taking food with curry but not seen on taking curd rice.
PAST HISTORY :
- k/c/o type 2 DM since 15years and on INJ HUMAN MIXTARD 5U morning, 6U night and TAB VILDAGLIPTIN 50MG + TAB METFORMIN 500MG in afternoon.
- k/c/o hypothyroidism since 1 1/2 year and on TAB THYRONORM 25MCG.
- h/o b/l cataract surgery 1year ago
PERSONAL HISTORY :
Diet - mixed
Appetite - decreased
Sleep - adequate
No addictions
DIETARY HISTORY :
Breakfast - ragi malt
Lunch - 1cup rice with curry
Dinner - 1cup rice with curry
She consumes meat once in 15-20days
OBSTETRIC HISTORY :
1st child - son, 21years, FTNVD
2nd child - daughter, 19years, FTNVD
h/o tubectomy 19years back
GENERAL EXAMINATION :
Patient is c/c/c
No pallor, icterus, cyanosis, clubbing, lymohadenopathy, pedal edema
VITALS AT THE TIME OF ADMISSION :
TEMP - 98.2F
BP - 110/60MM HG
PR - 82BPM
RR - 17CPM
SPO2 - 97% @ROOM AIR
GRBS - HIGH (>450MG/DL)
SYSTEMIC EXAMINATION :
CVS : S1S2+
RS : BAE +
P/A : SOFT, NON TENDER
CNS : NAD
INVESTIGATIONS :
FASTING BLOOD SUGAR :
BLOOD GROUPING :
HEMOGRAM :
CUE :
BLOOD UREA :
ABG :
LIPID PROFILE:
LFT :
SERUM CREATININE :
SERUM ELECTROLYTES :
THYROID PROFILE:
URINE FOR KETONE BODIES : NEGATIVE
SEROLOGY : NEGATIVE
CHEST X RAY PA VIEW :
2-D ECHO :
USG ABDOMEN AND PELVIS :
GRAVINDEX TEST :
OBG REFERRAL WAS DONE I/V/O AMENORRHOEA :
OPHTHALMOLOGY REFERRAL DONE I/V/O ? DIABETIC RETINOPATHY :
ENDOCRINOLOGY REFERRAL :
OUTSIDE HBA1C DONE :
DIAGNOSIS : UNCONTROLLED SUGARS WITH TYPE 2 DM SINCE 15YRS AND HYPOTHYROIDISM SINCE 1 1/2 YEAR WITH SECONDARY AMENORRHOEA WITH CKD
TREATMENT :
1. NBM TILL FURTHER ORDERS
2. IVF - NS, RL @ 125ML/HR
3. INJ HUMAN ACTRAPID INSULIN 6ML/HR
4. INJ PAN 40MG IV OD
5. INJ ZOFER 4MG IV TID
6. INJ OPTINEURON 1AMP IN 100ML NS IV OD
7. GRBS MONITORING HOURLY
GRBS CHARTING AND INSULIN INFUSION:
SOAP NOTES
27/5/2022
DAY 1
S :
Vomitings reduced
No fever spikes
O :
Patient is c/c/c
BP - 110/80 mm Hg
PR - 78 bpm
RR - 21 cpm
Spo2 - 98% @ room air
GRBS @ 8am - 158 mg/dL (7U HAI + 10U NPH)
CVS - S1S2 +
RS - BAE+
P/A - soft, nontender
CNS - NAD
INVESTIGATIONS :
FASTING BLOOD GLUCOSE : 140 MG/DL
A :
UNCONTROLLED SUGARS WITH TYPE II DM SINCE 15YRS
HYPOTHYROIDISM SINCE 1 1/2YEAR WITH SECONDARY AMENORRHOEA
? CKD
P :
1. ORALLY ALLOWED - SOFT DIET
2. IVF - NS, RL @ 100ML/HR
3. INJ INSULIN
8am - 7U HAI + 10U NPH
2pm - 7U HAI
8pm - 7U HAI + 10U NPH
4. INJ PAN 40MG IV OD
5. INJ ZOFER 4MG IV TID
6. INJ OPTINEURON 1AMP IN 100ML NS IV OD
7. GRBS ACCORDING TO 7-PROFILE
8. TAB THYRONORM 25MCG PO OD
SOAP NOTES
28/5/2022
DAY 2
S :
c/o nausea while eating
No fever spikes
O :
Patient is c/c/c
BP - 120/80 mm Hg
PR - 92 bpm
RR - 22 cpm
Spo2 - 99% @ room air
GRBS @ 8am - 163 mg/dL (7U HAI + 10U NPH)
GRBS TRENDS : 27/5/2022
9am - 204 mg/dL (7U HAI + 10U NPH)
11am - 282 mg/dL
2pm - 307 mg/dL (7U HAI)
4pm - 147 mg/dL
8pm - 153 mg/dL (7U HAI + 10U NPH)
10pm - 198 mg/dL
2am - 72 mg/dL
CVS - S1S2 +
RS - BAE+
P/A - soft, nontender
CNS - NAD
INVESTIGATIONS :
SERUM ELECTROLYTES :
Na - 140
K - 3.4
Cl - 101
A :
UNCONTROLLED SUGARS WITH TYPE II DM SINCE 15YRS
HYPOTHYROIDISM SINCE 1 1/2YEAR WITH SECONDARY AMENORRHOEA
? CKD
P :
1. ORALLY ALLOWED - SOFT DIET
2. IVF - NS, RL @ 100ML/HR
3. INJ INSULIN
8am - 7U HAI + 10U NPH
2pm - 7U HAI
8pm - 7U HAI + 8U NPH
4. INJ PAN 40MG IV OD
5. INJ ZOFER 4MG IV TID
6. INJ OPTINEURON 1AMP IN 100ML NS IV OD
7. GRBS ACCORDING TO 7-PROFILE
8. TAB THYRONORM 25MCG PO OD
9. SYP POTCHLOR 10ML IN 1GLASS OF WATER PO TID
SOAP NOTES
29/5/2022
DAY 3
S :
Nausea subsided
No fever spikes
O :
Patient is c/c/c
BP - 110/80 mm Hg
PR - 80 bpm
RR - 22 cpm
Spo2 - 99% @ room air
GRBS @ 8am - 144 mg/dL (7U HAI + 10U NPH)
GRBS TRENDS : 28/5/2022
8am - 163 mg/dL (7U HAI + 10U NPH)
10am - 213 mg/dL
2pm - 123 mg/dL (7U HAI)
4pm - 101 mg/dL
8pm - 106 mg/dL (7U HAI + 8U NPH)
10pm - 171 mg/dL
2am - 81 mg/dL
CVS - S1S2 +
RS - BAE+
P/A - soft, nontender
CNS - NAD
A :
UNCONTROLLED SUGARS WITH TYPE II DM SINCE 15YRS
HYPOTHYROIDISM SINCE 1 1/2YEAR WITH SECONDARY AMENORRHOEA
? CKD
P :
1. DIABETIC DIET
2. IVF - NS, RL @ 100ML/HR
3. INJ INSULIN
8am - 7U HAI + 10U NPH
2pm - 7U HAI
8pm - 7U HAI + 8U NPH
4. INJ PAN 40MG IV OD
5. INJ ZOFER 4MG IV TID
6. INJ OPTINEURON 1AMP IN 100ML NS IV OD
7. GRBS ACCORDING TO 7-PROFILE
8. TAB THYRONORM 25MCG PO OD
9. SYP POTCHLOR 10ML IN 1GLASS OF WATER PO TID
10. SYP CREMAFFIN 15ML PO H/S
SOAP NOTES
30/5/2022
DAY 4
S :
Nausea subsided
No fever spikes
O :
Patient is c/c/c
BP - 120/80 mm Hg
PR - 75 bpm
RR - 22 cpm
Spo2 - 99% @ room air
GRBS @ 8am - 155 mg/dL (7U HAI + 10U NPH)
GRBS TRENDS : 29/5/2022
8am - 144 mg/dL (7U HAI + 10U NPH)
10am - 147 mg/dL
2pm - 72 mg/dL (7U HAI)
4pm - 221 mg/dL
8pm - 138 mg/dL (7U HAI + 8U NPH)
10pm - 172 mg/dL
2am - 165 mg/dL
CVS - S1S2 +
RS - BAE+
P/A - soft, nontender
CNS - NAD
INVESTIGATIONS :
BLOOD UREA : 19
SERUM CREATININE : 1.8
SERUM ELECTROLYTES :
Na - 144
K - 4.0
Cl - 98
A :
UNCONTROLLED SUGARS WITH TYPE II DM SINCE 15YRS
HYPOTHYROIDISM SINCE 1 1/2YEAR WITH SECONDARY AMENORRHOEA
? CKD
P :
1. DIABETIC DIET
2. IVF - NS, RL @ 75 ML/HR
3. INJ INSULIN
8am - 7U HAI + 10U NPH
2pm - 7U HAI
8pm - 7U HAI + 8U NPH
4. INJ PAN 40MG IV OD
5. INJ ZOFER 4MG IV SOS
6. GRBS ACCORDING TO 7-PROFILE
7. TAB THYRONORM 25MCG PO OD
8. SYP CREMAFFIN 15ML PO H/S
