8 THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have 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 diagnosis and treatment plan.
A 26 year old male patient came to op with the chief complaints of loose stools since 20 days.
Pt was apparently asymptomatic 2 months ago , then he developed bilateral flank pain. He also developed loose stools which were insidious in onset with 4-5 episodes per day( 10 days liquid consistency, 10 days hard consistency) and was suffering from generalized body weakness since 3 months, which was not associated with nausea, vomiting, Fever.
Past history:-
He is a known case of DM since 3 years ( on irregular medication stopped taking insulin 7 months ago)
No h/o of htn, tb, epilepsy
K/c/o of polio
Drug history:-
He is currently on isophane insulin 30 /70 .
PERSONAL HISTORY:-
Diet- mixed
Appetite - increased
Sleep -inadequate
Bowel and bladder -increased(bowel almost 10to 12 times daytime and 5 to 6 times at night)
Addictions- alcohol 90ml every day
FAMILY HISTORY-
no significant family history
GENERAL EXAMINATION-
patient was consious coherent and coperative and well oriented to time place and person.
Temp- afebrile
Bp: 110/ 70 mmHg
PR: 90bpm
RR-18 cpm
GRBS- 132mg/dl at 8 am (19/8/22-high 20/8/22- 2 am : 218mg/dl at 7 pm : 384mg/dl 21/8/22-at 12 am 347mg /dl &7 pm 88 mg/dl)
No PICKLE
CVS: S1 S2+
CNS: NAD
Lungs: BAE+
P/A:- soft and non tender
PROVISIONAL DIAGNOSIS:- chronic diarrhea under evaluation
Aa
Plan of treatment:
1.IVF-2× NS @75 ml/hr 2× RL@75ml/hr
2.INJ.HAI 6U IV STAT
3.GRBS 7 POINT PROFILE
4.BP/PR/TEMP CHARTING 8th hourly
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