09-12-2024
This is an Online E Log Book to discuss our patient's de-identified health data shared after taking her signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.
This is a case of 68yr old female patient who came with complaints of severe vomitings and pain when passing stools. This problem of vomitings was experienced 5 yrs back. But since 1-2 yrs the patient's problem became severe with vomitings and pain when passing stools for every month. From August 2024, this was a regular feature for the patient. Her sugar levels became high and was on insulin. Since 10 days the patient experienced severe vomitings and loose stools and could not digest any food items except raagi malt and some fluid items. She was taken to hospital for treatment and was advised some package sugar treatment which costed more than 3k.
Some of her symptoms were temporary forgetfulness and being mild and lethargic. The patient was again taken to hospital and was diagnosed with sugar of 650mg/dl. Panicked with her sugar level the family members opted for the 6k package and joined her in the hospital. But as they could not afford, they took the advise of a local pharmacist to admit her in the present hospital. At first she was treated for diabetes. But her pain in the abdomen and vomitings showed no respite. She remained undiagnosed for a few days. One day a senior doctor suspected her problems to be due to an obstructed incisional hernia and she was taken up for surgery. Then she was confirmed with Hernia. Later she was operated and had relief.
70F admitted with @PPM3 @PPM4. On review now she appears to be having an obstructed incisional hernia! Pain abdomen for 4 months and vomiting since 10 days!
https://pmc.ncbi.nlm.nih.gov/articles/PMC10910421/
PPM 1 - 👆 Similar
PPM 1 - Mentioning diagnosis
Amazing! She developed diabetic ketoacidosis during the post operative phase! We missed all that action as she didn't have a PaJR.
24-12-2024
@PGs while it was planned that she would receive glimiperide 2.5 mg yesterday by adding half tablet from the separate 1mg of glimiperide they bought, she was actually given the same tablet of glimiperide 2mg in combination with metformin (one of the reasons these combinations are discouraged). Due to that confusion as she was still hyperglycemic, she wasn't even given the usual dose of glimiperide and metformin today but was given the 1mg of glimiperide alone in the morning because of which her post breakfast also came high and hence the duty PG decided to restart insulin
26-12-2024
PPM 1 -
OHAs were stopped after 24/12/24 and since afternoon yesterday she was started again on insulin with a higher NPH that nearly caused hypoglycemia (while the measured sugars were 75) and the patient appeared a bit dull at midnight as per the patient's advocate who was near the patient at that time.
PPM 1 - Today's sugars on the basal bolus regime.
EMR SUMMARY
Age/Gender : 72 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 17/12/2024 06:14 PM
Date of Operation
EMERGENCY EXPLORATORY LAPAROTOMY +ADHESIONOLYSIS + OMENTECTOMY UNDER GA DONE ON 9/12/24
Diagnosis
INCISIONAL HERNIA WITH SMALL BOWEL OBSTRUCTION
K/C/O HYPERTENSION , DIABETIES MELLITUS , CORONARY ARTERY DISEASE [ S/P PTCA] + DIABETIC KETOACIDOSIS(RESOLVED) WITHGRADE 1 BEDSORE
https://pajrcasereporter.blogspot.com/2024/12/70f-with-incisional-hernia-pain-abdomen.html?m=1
Case History and Clinical Findings
C/O VOMITINGS AND PAIN ABDOMEN SINCE 10 DAYS HISTORY OF PRESENT ILLNESS :
PT WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK THEN DEVELOPED PAIN ABDOMEN DIFFUSE ASSOCIATED WITH 3-4 EPISODES OF NON BILIOUS,NON PROJECTILE,NON BLOOD TINGED VOMITINGS IMMEDIATELY AFTER FOOD INTAKE .
H/O LOOSE STOOLS 5 DAYS BACK WATERY ,NON BLOOD TINGED . NO H/O OUT SIDE FOOD INTAKE , FEVER .
NO H/O GIDDINESS , PROFUSE SWEATING ,#
NO H/O COUGH , COLD BREATHLESSNESS , CHEST PAIN , ORTHOPNEA , PND HISTORY OF PAST ILLNESS :
H/O SIMILAR COMPLAINTS IN THE PAST , K/C/O TYPE II DM SINCE 10 YRS ON TAB GLIMI M2 BD, HTN SINCE 10 YRS AND ON TELMA 40 MG AND METPROLOL 25 MG
H/O CAD SINCE 10 YRS S/P PTCA ON ECOSPIRIN GOLD 75/75/20 ON EXAMINATION-
PT IS C/C/C
NO PALLOR ,NO ICTERUS , NO CLUBBING , NO CYANOSIS , NO LYMPADENOPATHY PR- 96 BPM
RR- 17CPM
BP -120/80MMHG
CVS - S1S2 + NO MURMUR CNS -NFND
RS -BAE +
Investigation
COMPLETE BLOOD PICTURE (CBP) 17-12-2024 06:43:PMHAEMOGLOBIN 9.2 gm/dl 15.0-12.0
gm/dlTOTAL COUNT 12100 cells/cumm 10000-4000 cells/cummNEUTROPHILS 82 % 80-40
%LYMPHOCYTES 13 % 40-20 %EOSINOPHILS 01 % 6-1 %MONOCYTES 04 % 10-2
%BASOPHILS 00 % 2-0 %PLATELET COUNT 3.50SMEAR Normocytic normochromic anemia with neutrophilic leucocytosisCOMPLETE URINE EXAMINATION (CUE) 17-12-2024 06:43:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN ++SUGAR +BILE SALTS NilBILE PIGMENTS NilPUS CELLS 4-5EPITHELIAL CELLS 2-4RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilHBsAg-RAPID 17-12-
2024 06:43:PM NegativeAnti HCV Antibodies - RAPID 17-12-2024 06:43:PM Non ReactiveRFT 17- 12-2024 06:44:PMUREA 40 mg/dl 50-17 mg/dlCREATININE 0.9 mg/dl 1.2-0.6 mg/dlURIC ACID 3.8
mmol/L 6-2.6 mmol/LCALCIUM 9.3 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.0 mg/dl 4.5-2.5
mg/dlSODIUM 143 mmol/L 145-136 mmol/LPOTASSIUM 3.9 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
106 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 17-12-2024 06:44:PMTotal Bilurubin 2.16
mg/dl 1-0 mg/dlDirect Bilurubin 0.33 mg/dl 0.2-0.0 mg/dlSGOT(AST) 43 IU/L 31-0 IU/LSGPT(ALT) 42
IU/L 34-0 IU/LALKALINE PHOSPHATASE 154 IU/L 141-53 IU/LTOTAL PROTEINS 5.2 gm/dl 8.3-6.4 gm/dlALBUMIN 2.59 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.99SERUM ELECTROLYTES (Na, K, C l) 17- 12-2024 11:51:PMSODIUM 141 mmol/L 145-136 mmol/LPOTASSIUM 3.5 mmol/L 5.1-3.5 mmol/LCHLORIDE 106 mmol/L 98-107 mmol/LSERUM ELECTROLYTES (Na, K, C l) 19-12-2024 12:13:AMSODIUM 136 mmol/L 145-136 mmol/LPOTASSIUM 3.2 mmol/L 5.1-3.5 mmol/LCHLORIDE
98 mmol/L 98-107 mmol/L USG DONE ON 18/12/24 IMPRESSION-
EVIDENCE OF MILD INFLAMMATORY AND EDEMATOUS CHANGES ALONG THE SUTURE SITE NO E/O ANY COLLECTION
Treatment Given(Enter only Generic Name)
SX DONE :
EMERGENCY EXPLORATORY LAPAROTOMY + ADHESIOLYSIS + OMENTECTOMY . TREATMENT GIVEN-
POTASSIUM RICH DIET TAB GLIMI- M2 PO/BD
TAB TENEGLIPTIN 20 MG PO/ OD BEFORE LUNCH TABPAN 40 MG PO/OD
TAB MVT PO/OD TAB VIT C PO/OD
TAB SPOROLAC 2TABS PO/BD
Advice at Discharge
POTASSIUM RICH DIET
TAB GLIMI- M2 PO/BD TO CONTINUE
TAB TENEGLIPTIN 20 MG PO/ OD BEFORE LUNCH TO CONTINUE TABPAN 40 MG PO/OD X 5DAYS
TAB MVT PO/OD X 5DAYS TAB VIT C PO/OD X 5DAYS ABDOMINAL BINDER
Follow Up
REVIEW TO GS OPD AFTER 2 WEEKS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date:26/12/24 Ward:SICU
Unit: I
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