patient came with shortness of breath, altered sensorium, GRBS high 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. She was initially on OHA and
since 3 years on insulin 20 units in the morning and 10 units in evening.
Now she came with chief 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 -
Diet - mixed,
Appetite decreased since 2 days
Bowel and bladder - regular .
no addictions.
Vitals -
Bp -150/100 mm Hg
PR -134 bpm
RR - 32 cpm
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 -
Treatment -
1. IV fluids
2. Insulin infusion
Discharge summary -
