patient came with shortness of breath, altered sensorium, Grbs HI and urine ketones positive.


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 in the  log.

 Chief complaints;-

A 51 year old female patient, is a known case of diabetes mellitus since 20 yrs, and she is initially on OHA and 
since 3 years she is on insulin 20 units in the morning and 10 units in evening.

 Now she ...Came with cheif complaints of..  
Pain in right hypochondrium and epigastrium since 4 days.

No h/o blood in vomitus.
Patient has loss of appetite since 2 days.

Patient didn't take her  Regular dose of insulin , As she didn't eat anything.

 No h/o  fever, pain abdomen , loose stools, no h/o cough.
N/o yellow discoloration of eyes, pedal edema, chest pain, palpitations.

She has C/o  altered sensorium , on 12/06/2021 early morning.

Past history:- 
H/o hysterectomy 20 yrs back.
No H/o hypertension,asthma, epilepsy, TB.

 Personal history:-
Her diet is mixed, 
Appetite decreased since 2 days
Bowel and bladder - regular .
no  addictions.

 Vitals:-
Bp:-150/100
PR:-134
RR:-32
TEMP:- AFEBRILE
SPO2 :-100% on room air
GRBS:- HIGH (>500) AT ADMISSION.

On examination:-
Patient is conscious, coherent , cooperative.

Abdominal examination:-
Tenderness in Right hypochondrium and epigastrium.
No palpable mass.
 
Cvs:- 
S1 S2 heard,
No thrills , no murmurs.

Respiratory system:-
BAE:- present 
           Nvbs.
 CNS :- intact.

  Investigations:-









ECG:-



Treatment:-
1. IV fluids 
2. Insulin infusion

Discharge summary:-



Comments

Post a Comment

Popular posts from this blog

A 49 yr old female with generalized weakness and vomitings

Image
This is an online e-log platform to discuss case scenarios of a patient with their guardian\"s permission. 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 a diagnosis and treatment plan. ★ CASE SCENARIO : *A 49 yr old female , mother of 2 children, who is a  house wife,   apparently asymptomatic 13 yrs ago and then she noticed mass per anum with bleeding , went to hospital and diagnosed as haemorrhoids and got operated. - Since 3 yrs she has history of muscle aches, for which she is using NSAIDs. - She has h/o fever 20 days back, got treated in the local hospital, and  - Since 20 days she has generalized weakness. - She also has h/o vomitings since 3 days, with food as content, non - projectile , non bilious. - Urine output - Normal  - No fatigability , pedal oedema ,  -  No SOB , fa
Read more

A 50 yr old patient with giddiness, and dry cough.

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 in the log.  Chief complaints;- A 50 yr old female came to the OPD with the chief complaints of.. Giddiness since 1 week ..     associated with blurring of vision( intermittent). Dry cough since 2 days Fever with chills since 1 day... History of present illness:- Patient was apparently asymptomatic 2 yrs ago, then she had high grade fever, associated with chills, red coloured urine, burning micturition,which was diagnosed as emphysematous pyelonephritis. Stenting was done and removed 2 yrs ago
Read more

72 yr old female with fever, vomitings and loose stools.

Image
This is 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 patients clinical problems with collective current best evidence based inputs.  Case:- 72yr old female  came to the casualty with c/o vomitings since 3 days, fever since 3 days loose stools since 1 day . Fever :  Low grade, intermittent, not associated with chills and rigors , associated with decreased Appetite, loose stools and vomiting. Vomitings:-  3-4 episodes per day, non - bilious , non - projectile, food/ water as content. Stools:-  10-12 episodes/day, green in colour associated with lower abdominal pain- diffuse, squeezing type, no aggrevating and relieving factors. Patient was apparently asymptomatic 6 months back, from then she decreased using her left lower limb , walking with support (
Read more