A 24 year old male with diabetic keto acidosis

E-LOG GENERAL MEDICINE

Hi, This is G. Nandini a third semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.  
   
A CASE OF DIABETIC KETOACIDOSIS

CHIEF COMPLAINTS:

A 24 year male patient sand contractor by occupation came with chief complaints of

* Loss of appetite and generalised weakness since 1 week

HISTORY OF PRESENT ILLNESS:

*  patient was apparently asymptomatic 1 week back then he had generalized weakness associated with loss of appetite and loss of weight(2kg)
 . 
* There is no associated fever, vomitings, loose stools. Pain abdomen, chest pain, palpitations. 

HISTORY OF PAST ILLNESS:

*  2 Weeks back patient  have episode of giddiness went to local RMP and  found to be having high BP (170/120mm of hg) and gave tablets and injections for 2 days. 

Not k/c/o Diabetes, asthma, tuberculosis, epilepsy

No previous surgeries and blood transfusions. 
 
K/c/o hypertension. 

PERSONAL HISTORY:

He is unmarried. 

 Mixed diet. 

Appetite :Normal

Micturtion: Normal

Bowel and bladder habits : Normal

No addictions. 

FAMILY HISTORY:

Has no family h/o  HTN, TB, heart disease,cancers, epilepsy. 

Family h/o of DM (father) 

GENERAL EXAMINATION : 

Vitals :

• BP - 150/70 mmHg

• Temp. - 98.4°

• SpO2 - 98%

• RR - 24 cycles/min

• PR - 84 bpm

•GRBS : 472 mg%

PALLOR : Absent

ICTERUS : Absent

CYANOSIS :Absent

CLUBBING :Absent
 
GENERALIZED LYMPADENOPATHY :Absent

ODEMA :Absent
  
SYSTEMIC EXAMINATION :


CVS:

• S1, S2 heard

• No thrills and cardiac murmurs

RESPIRATORY SYSTEM:

• No dyspnoea, wheezing

• Postion of trachea - central

• Breath sounds - Vesicular

ABDOMEN:

• No tenderness, palpable mass, bruits

• No palpable liver and spleen

•Shape :Schapoid

CNS:

• Conscious and coherent

• Speech - normal

• No signs of meningeal irritation

• Glass gow coma scale - 15/15

PROVISIONAL DIAGNOSIS:

• DIABETIC KETOACIDOSIS

TREATMENT:
On 1/3/2022
Rx:
1. 1ml HAI +39ml NS @ 6ml/hr
2.IV NS Continuous infusion@200ml/hr
3.GRBS 1 Hourly
4. Strict I/O charting

2/3/2022

1ml HAI +39ml NS @ 6ml/hr
2.IV NS Continuous infusion@200ml/hr
3.GRBS 1 Hourly
4. Strict I/O charting

3/3/2022
1.Inj HAI 100-100-100
        NPH 100-X-100
2.INJ Thiamine 1amp in100 ml NS IV (TID) 
3.GRBS before  food and  2 hrs after food. 
4.Strict I/O charting

4/3/2022
1.Allow soft diet
2.Tab GLIMY-M1PO/BD
3.GRBS before  food and  2 hrs after food. 
4.INJ Thiamine 1amp in100 ml NS IV (TID) 
5.Monitor vitals
6.I/O charting

INVESTIGATIONS:








Comments

Post a Comment

Popular posts from this blog

BLENDED BIMONTHLY ASSESSMENT

  G. NANDINI ROLL NO : 38 , 3 RD SEM QUESTION 1: LONG CASE: LINK:  https://2018- 21batchpgy3gmpracticals. blogspot.com/2021/08/ 18100006003-case- presentations.html?m=1    This long case presentation is very nice even a 2 nd year mbbs student can understand the case very well. Because in the case first everything that patient said is written in his words and next the cause for each and every symptom is explained in his words and from that a provisional diagnosis is made and if it's the provisional diagnosis to confirm it what are the features we should look into is explained in detailed manner. Then all inspection  findings  are seen in the photographs that attached in the log. Which is very good because anyone who look the log can easily understand how the patient actually presented to opd. The very beautiful thing in this is he also explained the x-ray of the patient and we can understand much better due to this and then Disscussed about diagnostic approach with all scientific pr
Read more

A 25 year old female with fever and petechiae

Image
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients' problems through a series of inputs from an available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence based input. The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.  A 25 year old female came to the opd with cheif complaints of  Fever since 3 days Loose stools since morning - (5-6 times)  Vomitings since morning (3 episodes)  HOPI : Patient was apparently asymptomatic 3 days ago then she developed fever which was insidious in onset  gradually progressive high grade. No aggravating and relieving factors. Passage of loose stools , watery since 1 day and vomiting sin
Read more