52 yr female with uncontrolled sugars with Tenia infection??

-
"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 patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment"



A 52 yr old female with c/o swelling over the left retroauricular and angle of mandible since 3 days.
C/o swelling associated with increase in local temperature of left leg since 2 weeks.

History of present illness:
Pt was apparently asymptomatic 2 wks back then she developed progressive swelling of the left leg associated with local rise of temp since 2 wks.swelling over the angle of mandible which was preceded by a swelling and pain over the mastoid region.
H/O cutaneous fungal annular lesions over the trunk,thighs s/o Tenia infection.

Past history:
K/c/o Hypertension since 2 yrs on tab.TELMA 40 mg /po/od
K/c/o Type 2 diabetes mellitus since 8 yrs on Inj.Human Actrapid Insulin 8u-15u-10u
Tenia corporis et.cruris since 2 mnths
S/p LSCS 30 yrs ago
S/p Hernioplasty 7 yrs ago

Personal history:
Appetite- Normal
Bowels- Regular
Micturition- normal
Not Alcoholic
Sleep- Adequate
On 25/05/22:
On examination:
No pallor/icterus/cyanosis/clubbing/lymphadenopathy/edema

Vitals :
Bp 120/80 mm hg
PR 86bpm
RR 16 cpm
Temp afebrile
GRBS 182 mg/dl
Systemic examination:
CVS - s1 s2 heard
RS- BAE+
CNS - NAD
P/A- soft, non tender

PROVISIONAL DIAGNOSIS:
TINEA CORPORIS WITH UNCONTROLLED SUGARS WITH T2 DM WITH HTN WITH B/L PAROTID ENLARGEMENT.
Treatment given:
1.T.TELMA 40 mg PO/OD
2.T.METXL 50 mg PO/OD
3.Inj.HAI S/C ACC TO GRBS
4.LUCIFIN CREAM L/A BD ON LEG LESION
5.MOMATE -S - CREAM L/A OD ON NECK LESION
6.TAB.ATARAX 10 Mg PO/OD
7.INJ.MONOCEF 1gm/IV/BD
8.INJ.OPTINEURON 1 AMP IN 100 ML NS/IV/OD
9.VITALS MONITORING 4TH HRLY
10.GRBS MONITORING 6TH HRLY

AMC 25/05/22 admission

SOAP notes: Day 1

S: No fresh complaints

O:
O/E pt c/c/c
No pallor/icterus/clubbing/lymphadenopathy/edema
Temp - 98 f
Bp- 120/80 mm Hg
RR- 16cpm
PR- 86bpm
CVS- S1 S2 heard
RS- BAE +
CNS - NAD
GRBS - 301 mg/dl

A - Tinea corporis with uncontrolled sugars with T2 DM with HTN with B/L PAROTITIS

P:
1.T.TELMA 40 mg PO/OD
2.T.METXL 50 mg PO/OD
3.Inj.HAI S/C ACC TO GRBS
4.LUCIFIN CREAM L/A BD ON LEG LESION
5.MOMATE -S - CREAM L/A OD ON NECK LESION
6.TAB.ATARAX 10 Mg PO/OD
7.INJ.MONOCEF 1gm/IV/BD
8.INJ.OPTINEURON 1 AMP IN 100 ML NS/IV/OD
9.VITALS MONITORING 4TH HRLY
10.GRBS MONITORING 6TH HRLY

AMC admission

SOAP notes: Day 2

S: No fresh complaints

O:
O/E pt c/c/c
No pallor/icterus/clubbing/lymphadenopathy/edema
Temp - 98.2f
Bp- 130/80 mm Hg
RR- 20cpm
PR- 80bpm
CVS- S1 S2 heard
RS- BAE +
CNS - NAD
GRBS - 249 mg/dl @7Am 27/05/22

A - Tinea corporis with uncontrolled sugars with T2 DM with HTN with B/L PAROTITIS

P:
1.T.TELMA 40 mg PO/OD
2.T.METXL 50 mg PO/OD
3.Inj.HAI S/C ACC TO GRBS
4.LUCIFIN CREAM L/A BD ON LEG LESION
5.Tab.TERBINAFIN 250 Mg/OD
6.TAB.ATARAX 10 Mg PO/OD
7.INJ.MONOCEF 1gm/IV/BD
8.INJ.OPTINEURON 1 AMP IN 100 ML NS/IV/OD
9.VITALS MONITORING 4TH HRLY
10.GRBS MONITORING 6TH HRLY
AMC admission

SOAP notes: Day 3

S: c/o joint pains

O:
O/E pt c/c/c
No pallor/icterus/clubbing/lymphadenopathy/edema
Temp - 98.5f
Bp- 130/70 mm Hg
RR- 19cpm
PR- 84bpm
CVS- S1 S2 heard
RS- BAE +
CNS - NAD


A - Tinea corporis with uncontrolled sugars with T2 DM with HTN with B/L PAROTITIS

P:
1.T.TELMA 40 mg PO/OD
2.T.METXL 50 mg PO/OD
3.Inj.HAI S/C ACC TO GRBS
4.LUCIFIN CREAM L/A BD ON LEG LESION
5.Tab.TERBINAFIN 250 Mg/OD
6.TAB.ATARAX 10 Mg PO/OD
7.INJ.MONOCEF 1gm/IV/BD
8.INJ.OPTINEURON 1 AMP IN 100 ML NS/IV/OD
9.VITALS MONITORING 4TH HRLY
10.GRBS MONITORING 6TH HRLY
Ortho referral done:
SOAP notes: Day 4

S: No fresh complaints

O:
O/E pt c/c/c
No pallor/icterus/clubbing/lymphadenopathy/edema
Temp - 97.5f
Bp- 130/80 mm Hg
RR- 18cpm
PR- 86bpm
CVS- S1 S2 heard
RS- BAE +
CNS - NAD


A - Tinea corporis with uncontrolled sugars with T2 DM with HTN with B/L PAROTID ENLARGEMENT

P:
1.Normal diabetic diet
2.Inj.Monocef 1gm /Iv/BD
3.Inj.Metrogyl 500 mg/IV/TID
4.Inj.Optineuron 1 AMP in 100 ml NS/IV/OD
5.Inj.Mixtard insulin (30/70) s/c  / BD
6.Inj.HAI s/c a/c to GRBS 
7.Tab.Telma 40 mg po/ OD
8.Tab.Met XL 50 mg PO/OD
9.Tab.Terbjnafine 250 mg /PO/OD
10.Tab.Atarax 10 Mg /PO/OD
11.Lulifin cream L/A B/D on leg
12.GRBS monitoring 6th HRLY
13.Monitor vitals
SOAP notes: Day 5

S: No fresh complaints

O:
O/E pt c/c/c
No pallor/icterus/clubbing/lymphadenopathy/edema
Temp - Afebrile
Bp- 130/90 mm Hg
RR- 20cpm
PR- 86bpm
CVS- S1 S2 heard
RS- BAE +
CNS - NAD


A - Tinea corporis with uncontrolled sugars with T2 DM with HTN with B/L PAROTID ENLARGEMENT

P:
1.Normal diabetic diet
2.Inj.Monocef 1gm /Iv/BD
3.Inj.Metrogyl 500 mg/IV/TID
4.Inj.Optineuron 1 AMP in 100 ml NS/IV/OD
5.Inj.Mixtard insulin (30/70) s/c  / BD
6.Inj.HAI s/c a/c to GRBS 
7.Tab.Telma 40 mg po/ OD
8.Tab.Met XL 50 mg PO/OD
9.Tab.Terbjnafine 250 mg /PO/OD
10.Tab.Atarax 10 Mg /PO/OD
11.Lulifin cream L/A B/D on leg
12.GRBS monitoring 6th HRLY
13.Monitor vitals
14.Tab.Zerodol BD
15.Tab.Shelcal PO/OD

Comments

Post a Comment

Popular posts from this blog

DRUG INDUCED HEPATITIS SECONDARY TO BORDERLINE LEPROMATOUS LEPROSY DAPSONE SYNDROME

-
Image
"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 patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment" 31 year old male who is a photographer by occupation came to the casuality with complaints of Yellowish discolouration of sclera since 4 days ,Fever since 2 days  which is  insidious on onset , gradually progressive , subsided on medication. C/o Nausea and vomitings since 2 days Non -bilious and non projectile , food particle as content and was taken to local hospital in view of vomitings .  Patient was apparently asymptomatic 17 years back then his mom observed hypopigmented p
Read more

General Medicine e-log book - 4

-
Image
Case: 55-Year-old female with palpitations, chest pain and shortness of breath           Written by Shravani Reddy, Roll no. 15, 8th Semester           I have been given this case to solve in an attempt to understand the topics of " Patient clinical data analysis " to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.      You can find the entire real patient clinical problem in the following link: https://himabindu5.blogspot.com/2020/05/hello-everyone.html Following is my analysis of this patient's problem: The problems in the order of priority according to my perspective are: Chest pain - From two months by the time case registered ( Admission date: May 23, 2020 ) Palpitations - From two months Shortness of breath Bilateral pedal edema up to ankle from one week Decreased urine output from one week Reasons: Chest pain: Source: www.verywellhealth.com Chest
Read more