General medicine short case history
July 31st, 2022
Final Practical examination (Short case)
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A 43 yr old female patient came to the casualty with a chief complaint of lower backache since 2 days , pain abdomen and vomiting since 1 day
History of present illness:
Patient was apparantly asymptomatic 6 yrs back , then she developed anasarca went to the local hospital then got diagnosed with hypothyroidism (tab.Thyronorm)& DM ( started on injection MIXTARD ) also with renal failure (tab.Torsemide 20 mg+ spironolactone 50mg)
Patient complaints of abdominal pain which is intermittent and also associated with vomitings (2 episodes/day)
No history of fever, cold, cough, loose stools, constipation,haematuria.
No history of pedal edema, decreased urine output, facial puffiness.
Past history:
Patient is known case of DM since 6 yrs and is on ( inj. MIXTARD ).
Patient is also known case of hypothyroidism since 5yrs ( tab thyronorm 25 micrograms)
No history of hypertension, asthma, epilepsy, tuberculosis.
Personal history:
Diet : mixed
Appetite : decreased
Sleep : adequate
Bowel& bladder movements : regular
No addictions.
Family history:
Patient mother is a known case of diabetes mellitus.
General examination:
Patient is conscious, coherent and cooperative
Patient is well oriented to time, person and place.
Patient is well built and nourished
No pallor , icterus, cyanosis, clubbing , generalized lymphadenopathy.
Vitals:
Temperature - Afebrile
Bp-150/80 mm hg
Pulse rate - 88bpm
Respiratory rate - 21cpm
Spo2- 99% on RA
Systemic examination:
RS- decreased breath sounds on B/L IAA & ISA
Cvs-S1 S2 +
P/A - soft, diffuse tenderness +
Cns- NAD
Investigations:
Provisional diagnosis:
Diabetic ketoacidosis
Treatment plan:
1) IVF – 0.9% NS @ 150ml/hr
2) INJ. PANTOP 40mg IV/OD
3)INJ.ZOFER 4mg IV/TID
4) INJ. METROGYL 500MG /IV / TID
5) INJ. TRAMADOL 1AMP IN 100 ML NS /IV/TID
6)INJ. INSULIN INFUSION WITH 2ML/HR
7)INJ.BUSCOPAN 2CC IV/SOS
8)INJ.LASIX 40MG IV/BD
9) TAB.THYRONORM 50microgram PO/OD
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