NOON REPORT 28.6.

11

History

25
.
CC: 11 mo PTA

PI
11 mo PTA:
10+
1 (
)

PI
5 mo PTA:. admit ATB
Albendazole 2 wk,
cef- 3,immodium,
metronidazole

5-6 weight loss 10 kg

refer

Past History
DMT1 with DR on Mixtard 20-0-6 u sc
Control BS

Alcohol: social drinking(2-3/wk)
Herb: positive

PE
V/S 112/80 mmHg, 120/80 mmHg
RR 20/min T36.8 C
GA: thin man,good consciousness
HEENT: not pale,no jaundice
LN: not palpable
Heart: normal S1, S2 no murmur
Lung: clear,no adventious sound

PE
Abd: soft, not tender, hyperactive BS
liver and spleen cannot palpable
PR: empty rectum, normal sphincter tone
no rectal shelf
Ext: no edema

Problem list
Chronic diarrhea
DMT1 with DR

Stool exam :loose,Not seen parasite, WBC:neg,

RBC:neg, occult blood:neg, fat:neg
Stool C/S for strongyloides:pending

Stool AFB:neg
UA: SpGr 1.032, pH 6.0, Alb:1+,Glu:4+,
blood:neg, WBC:1-2,RBC:neg

CBC
WBC 5300
N 49, L 40.5, M 9.5 , E 0.9, B 0.1
Hb 12, Hct 38.3, MCV 65.8
Plt 318,000

TFT:FT3 3.52, FT41.44,TSH2.22

Hepatitis profile:negative
HIV:negative

Blood chemistry
Na 141
K 3.8
Cl 100
HCO3 30.4
Ca 10.3
Mg 1.9
Po4 5.4
Urine amylase 990

BUN 13.7
Cr 0.7
FBS 282
HbA1c 9.3

LFT
Chol 178
TP 7.1
Alb 4.3
Glob 2.8
TB 0.4
DB 0.1

AST 35
ALT 66
ALP 90

EKG
NSR
Valsava EKG;
longest RR/shortest RR=1.07

Management
W/U infection
Control blood sugar
Long GI study
Hydration