medicine logs (log 2)

Hello everyone.. I am Aditya Rayilla, an intern posted in medicine department and one of the important terms of getting the internship completion is to complete my log book with my online log of what I learn during the course of my duties. 

Now coming to the case of 55 yo male patient that we had seen. 

This is discussed more in a brief way as this looks more like a classical case of gastro entiritis that we generally see in abundance and resolves after generic treatment. 

Diagnosis: 

Acute gastroenteritis with k/c/o Type-2 DM with post CABG with thrombocytopenia.

Day of admission (27/05/20)

Case History 

He is a 55 year old male who works as a volunteer in a political party came with complaints of loose stools. 10 episodes watery in consistency, greenish colour, small quantities, increased frequency since 26th morning

Fever since 25th evening intermittent in nature not associated with chills and rigors which got relived on taking medication 

One episode of vomiting 2 days back non bilious non projectile containing food particles not associated with pain abdomen

History of burning micturition since 2 days

Patient is also giving history that he visited few places in Narketpally and Nalgonda since one week

He is also saying that he is having decreased appetite since 2 days. 

No history of pain abdomen, chest pain, palpitations, dyspnea, cough, cold

He is known case of type 2 diabetes mellitus since 6 years was on tablet metformin 500mg and glimepride 2 mg once daily he did not take his medication in the last 4 days 

He is also giving history of jaundice 3 months back for which he did used Ayurvedic medication 

History of CABG in 2016

He is a chronic alcoholic 180ml per day since 20 years 

Chronic smoker -stopped since 2016

On examination Pt is febrile (100 degree F)

(Case history and treatment by our unit P.g's: Dr. Rashmitha ma'm and Dr. Ajith sir ).

Hemodynamically stable

GRBS-  388 mg /FL

And serum osmality is 297

 

General examination:

Pallor present 

Icterus absent 

No cyanosis clubbing lymphademopathy 

Dehydration present 

Temp 100F

Bp 130/80 mm hg

Pr 94  bpm

Cvs s1 s2 hears no murmurs

Rs BAE+

P/a soft, non tender

Cns 

Speech:normal

cranial nerves ,motor system,sensory system,intact 

Reflexes normal 

No cerebellar signs 

Treatment : 

1. ORS SATCHET 1 packet in 1L water 

2. IVF NS 50ml/hr

3.Inj. pantop 40mg/IV/OD

4.INJ. ZOFER 4MG/IV/OD

6.INJ. HAI/SC (8am-2pm-8pm)

7. plenty of oral fluids

8. temperature charting 4th hourly, tepid sponging

9. monitor bp/pr/spo2 4th hourly

10. GRBS charting 2nd hourly 

if grbs< 80mg/dl -- i.v 25%Dextrose, i.v stat

After treatment for 2 days the frequency decreased to 2-3 stools per day. 

AS OF TODAY  (30th May)

increased number of stool episode compared to yesterday (4 episodes)

O/E: pt c/c

Temp 98.4F

BP 110/80 mm hg

PR 84 bpm

CVS s1 s2 heard no murmurs

RS BAE+ NVBS

P/a soft, non tender

CNS: NAD

Investigations

HB: 16gm/dL

TLC: 4300

RBC: 4.83

Platelets: 60,000 

Treatment: 

1. T. Pan 40mg/OD

2. T. Glimiperide/BD 2mg * 1mg

3. T. Metformin 500mg * 1000mg

4. Strict GRBS charting 6th hourly 

5. T. B Plex Forte/OD

6. Plenty of oral fluids

7. ORSB sachet in 1 litre of water 20ml after each stool episode

8. Monitor BP PR RR

9. IVF 20NS 75ml/hour

Investigations: (updated on 31/05/20)

HB: 15.5gm/dL

TLC: 4400

RBC: 4.67

Platelets: 80,000

There are no abnormalities found in the stool examination sample as seen by the lab. The stool examination sample is also attached below in the link.

The reports of this patient and the nasolabial fold picture of the 65yo female is shared in the link below. 

https://drive.google.com/folderview?id=12U2y9heU406RHO6YqPyad-kvQx_dm6hv