03 Sai Tarun (24-08-21)

GENERAL MEDICINE CASE (24-08-21)

Welcome and greetings to every one who are visiting my blog. This is A.Sai Tarun of 3rd semester. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

DATE OF ADMISSION - 20/08/21

Introduction

- A 32 year old male came to casuality with H/O pain abdomen in epigastric region since afternoon and 2 episodes of vomitings and giddiness since afternoon and fever from 1 day.

Chief complaints and Duration

-Patient was apparently asymptomatic till yesterday and had sudden onset abdominal discomfort and vomiting of 1 episode - non bilious, on projectile food as content with epigastric pain-thrombing type ,non radiation not associated with constipation or loose stools.

HISTORY OF PRESENT ILLNESS

-Fever :1 episode and Morning high grade associated with chills and rigor, no diurnal variation not associated with cold, cough, SOB, headache.

-Patient then went to MP with C/O vomitings and epigastric pain.

-Last binge of alcohol yesterday.

HISTORY OF PAST ILLNESS 

-Given IV fluids , in hospital patient had one episode of giddeness - rotational not associated with headache ,palpitations , sweating, blackouts , blurring of vision ,diplopia.
-On presentation cold extremities + , pulse feeble, BP 70/40, and started on fluid resuscitation.

PERSONAL HISTORY

•Mixed diet

•Loss of appetite

•Sleep adequate

•Bowel and Bladder movements regular

•Regular alcohol drinker - 4times/day half quarter to 1 bottle since 20 yrs.

•(Tobacco)Kaini 1/day since 5yrs.

TREATMENT HISTORY 

 • Not k/c/o diabetes, HT, CAD , TB.

•NO H/O chemo /radiation , blood transfusion.

•NO H/O previous surgeries.

•Asthma since childhood -exacerbation when exposure to cold weather /foods and is on asthama inhaler.

FAMILY HISTORY 

• Father has H/O Diabetes.

GENERAL EXAMINATION

•Patient is conscious, coherent and cooperative

•Moderately built and Moderately nourished

•No signs of - Pallor

                       Cyanosis

                       Clubbing

                        Icterus

• Dehydration - Mild.

VITALS

•TEMP -99.4F

•Pulse rate -60bpm/low volume

•Respiratory rate - 12cpm

•BP- 70/40

•SPO2 - 97%

•GRBS - 96 mg%

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

•S1, S2 heard

•No murmurs

RESPIRATORY SYSTEM:

•NVBS heard

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - obese

•Tenderness in epigastric and hypochondrial region.

•No palpable mass

•No free fluid

•Spleen and liver not palpable

CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected

•Glasgow scale 15/15

CEREBRAL SIGNS:

• No finger nose incordination

•No knee heel incordination.

INVESTIGATIONS 

ULTRASOUND REPORT

21/08/21

22/08/21

23/08/21

PROVISIONAL DIAGNOSIS

-Septic shock

TREATMENT 

Rx

-Iv fluids NS and RL at 75 ml/hr

-INJ CEFTRIAXONE 1GM IV/BD

-INJ METROGYL 100ML IV/TID

-INJ PAN 40MG IV/BD

-INJ ZOFER 4MG IV/SOS

-INJ OPTINEURON 1amp in 100ml NS IV/OD

-TAB PCM 650MG TID

-TAB CHYMORAL FORTE TID

-Strict I/O Charting